THE 



HISTORY 



DIAGNOSIS, AND TREATMENT 



FEVERS 



UNITED STATES 



BY ELISHA BAETLETT, M.D., 

PROFESSOR OF THE THEORY AND PRACTICE OF PHYSIC IN THE MEDICAL DEPARTMENT OF 

TRANSYLVANIA UNIVERSITY; MEMBER OF THE AMERICAN ACADEMY OF 

ARTS AND SCIENCES ; AUTHOR OF AN ESSAY ON THE 

PHILOSOPHY OF MEDICAL SCIENCE, 

ETC. ETC. 





PHILADELPHIA: 
LEA AND BLANCHARD 

1847. .>v 



All diseases, then, ongm to oe reduced to certain and determinate kinds, mih the same 
exactness as \re see it done by botanic "writers, in their treatises of plants. For there are 
diseases that come under the same genus^ bear the same name, and have some symptoms in 
common, which, notwithstanding, being of a diflerent nature, require a different treatment. 
.... In writing, therefore, a history of diseases, every philosophical hypothesis- which 
hath prepossessed the writer in its favor, ought to be totally laid aside, and then the manifest, 
and natural phenomena of diseases, ho^wever minute, must be noted with the utmost accuracy, 
imitating in this the great exactness of painters, who in their pictures copy the smallest spots 
or moles in the ori^aa.ls.'-Sydsnhanu 



Entered according to the Act of Congress, in the year 1847, by 

LEA AND BLAXCHARD, 

in die Clerks Office of the District Court for the Eastern District of Pentisylvaiua, 



PHILADELPHIA : 
.XD P. G^. COLLTN-S, PEDTTEBS. 



TO 

JOHN ORNE GREEN, M.D., 

OF LOWELL, MASSACHUSETTS ; 

With whom the early and active part of the writer's life was 
passed; in a personal friendship w^hich no cloud, for a single 
moment, ever shadowed or chilled ; and in a professional inter- 
course whose delightful harmony no selfish interest nor personal 
jealousy ever disturbed; this volume, the best materials for which 
were gathered during the period thus consecrated by useful labors 
and social duties, and now endeared to us both by many sad and 
pleasant memories, is most affectionately inscribed. 

November 1st, 1847. 



rEEFxVCE TO THE FIRST EDITION, 



I HAVE ^v^itten this book, because I thought, that I saw a want 
ill medical literature, which it might supply. Our science, so 
far as the great subject of idiopathic fevers is concerned, is pass- 
ing through a transition period; and many authorities, that were 
received as standard and classical, only a few years ago, are fast 
becoming obsolete ; at least for American readers. This is par- 
ticularly true of the leading English treatises on Fever. Neither 
the works of Fordyce, Armstrong, Southwood Smith, nor Tweedie ; 
nor the elaborate articles on Fever, in the Medical Cyclopedias, 
Libraries, and Dictionaries, can henceforth be regarded as suffi- 
cient, or even safe, guides for American practitioners ; and the 
remark is applicable to them, not because they are not works of 
great excellence and value ; but for other reasons, which will be 
abundantly obvious in the course of the following pages. I may 
simply say, here, that their authors describe, principally, a fever, 
or form of fever, which is rarely met with in this country ; and that 
they do not represent the actual state of our knowledge upon this 
subject. It must be regarded as ^especially unfortunate, that, until 
within a few years^ the greater part of our information, relating 
to continued fever, has been derived from writers, who have 
treated, mostly, and under the same name as that generally used 
by ourselves, of a disease, or form of disease, differing, in many 
important respects, from that which is most common with us ; and 
that, in this way, so great a degree of confusion has been intro- 
duced into our notions of fever. 

If the radical defect in our literature of continued fever, thus 



yj PREFACE. 

indicated, had not existed ; and if the histories of the disease, 
which have been given to us by Louis, Chomel, and Andral, 
amongst the French; and by Nathan Smith, Dr. James Jackson, 
Dr. Hale, and some others, amongst ourselves, were generally ac- 
cessible, and generally read, there would have been no want such 
as I have alluded to ; and, certainly, I should not have added an- 
other to the long catalogue of books on fever. A translation, by 
Dr. Bowditch, of Louis's Researches, was published a few years 
ago under the auspices of the Massachusetts Medical Society, and 
has since been in the hands of most of its Fellows. But it is very 
far from being so generally and thoroughly known as it deserves 
to be. I may add, that the character of this remarkable work is 
hardly adapted to the actual wants and tastes of the great majority 
of our practical men. I may say this, I think, without any risk 
of giving offence ; for no man's admiration of this work can be 
more unqualified and profound than my own. Constituting, as it 
does, one of the few imperishable monuments, that have, from 
time to time, and at distant intervals, been raised up along the 
pathway of our science ; it is, nevertheless, true, that in the pre- 
sent state of the profession in this country; amidst the daily cares 
and duties of its active members, there are but few, who will de- 
vote to this object the time and the labor which are necessary, 
thoroughly to comprehend its principles, and to master its accu- 
rate and minute details. Chomel's Clinical Lectures, so far as I 
know, have not been published here ; Nathan Smith's Essay, ex- 
cellent as it is, is still very incomplete ; and the Reports of Dr. 
Jackson and Dr. Hale, besides not professing to treat systemati- 
cally of the disease, are not generally accessible. 

These, in brief, are the reasons, which have prompted me to 
undertake the preparation of this treatise. I thought, that the 
wants of medical science, here at least, demanded a history and 
comparison of the two chief forms of continued fever, as they are 
now ascertained to exist, fuller and more discriminating than had 
yet been written ; and these wants I have endeavored to supply. 
My book aims at no other excellence, and no higher merit, than 



PREFACE. Vll 

that of being a methodical and compendious summary of the 
actual state of our knowledge upon two most common and most 
important diseases. If it has reached this excellence, and if it 
possesses this merit, I am satisfied. 

I have only to add, in conclusion, that one of my leading pur- 
poses has been to bring out more clearly and strongly than has 
hitherto been done, our means of diagnosis between the different 
species or forms of fever ; and to ascertain and establish their 
nosological relations. It cannot be necessary to go into any formal 
vindication of the importance of this diagnosis. Setting it aside, 
altogether, as a matter of science ; it is the first, essential condi- 
tion of all sound practice. In the following history it will be no- 
ticed, that I have spoken of no individual fever, excepting the 
four, which are more or less fully described ; to wit, Typhoid 
Fever; Typhus Fever; Periodical Fever, in its three forms, of 
Intermittent, Bilious Remittent, and Congestive; and Yellow 
Fever. The simple reason of this is, that I do not know any- 
thing of any other distinct fever amongst us. There may be such 
a disease as the Simple Fever of Fordyce, or the Ephemera of 
many writers. I know, that adults, sometimes, in consequence 
of great, or protracted, fatigue ; and, that children, still oftener, 
from inappreciable causes, are attacked with headache, loss of 
appetite, debility, and general febrile excitement, not referable to 
any local origin ; which symptoms, after rest of from one to two 
or three days, either with or without medicine, usually subside, 
leaving the individual in good health. But whether this kind of 
disorder should be looked upon as a distinct, established form of 
fever, seems to me, to say the least of it, very doubtful. As to an 
Inflammatory Fever distinct from Typhus or Typhoid Fever, I 
can only say, with Nathan Smith, and Chomel, that I have no 
knowledge of any such disease. 

September 1st, 1842. 



PREFACE TO THE SECOND EDITION 



It \vill be seen by those who have read the first edition of my 
book on fevers, that the present is in some respects rather a new 
work, than a new edition of the former. The History of Typhoid 
and of Typhus Fever remains much in the same state in the pre- 
sent as in the first edition, with such additions and developments 
only as further observation and study have enabled me to make. 
The History of Periodical, and of Yellow Fever, constituting one 
half of the volume, has been added to the present edition ; thus 
rendering the w^ork what it professes to be, a Systematic and Me- 
thodical Treatise on the Fevers of the United States. 

N0TEMB£R 1st, 1S47. 



PREFACE. 



NOTE TO THE SECOND EDITION. 

Mr. James Moore, Surgeon, says, — " Synocha, or pure inflammatory fever, is a 
disease so rare in this country, that many experienced practitioners have doubted 
its existence." The same writer says that CuUen acknovi^ledged that he never saw 
the disease. 

Dr. Thomas Bateman, a sensible and judicious writer, says, — " With respect to 
Synocha, Dr. Cullen's distinguished successor, Dr. James Gregory, asserted, that 
during thirty years' practice, he had never seen a purely inflammatory fever uncon- 
nected with acute inflammation of some organ; and my own subsequent experience 
entirely coincides with that assertion. It cannot be doubted, as Dr. Gregory re- 
marked, that the causus, or ardent fever of the ancients, was the endemial bilious 
remittent of hotter climates, and that no continued fever of this country assumes 
that character." — A Succinct Account of the Contagious Fever, etc., p. 25. 

I may add, further, that the afi'ection described by most of our systematic writers' 
under the name of Infantile Remittent Fever, seems to me to have no existence as a 
distinct disease. Gastro-intestinal irritation ; bilious remittent fever; typhoid fever > 
and still other diseases are confounded under the foregoing term. 

NOVEMBEB 1st, 1847. 



CONTENTS 



PART I. 

TYPHOID FEVER. 

CHAPTER I. 

PAGE 

Prelimixaht Matters .-...-- 33 

Art. 1. — Introductory ...... 33 

Art. II. — Names of the Disease ..... 34 

Art. III.— History 3G 

Art. IV. — Methods of Description ..... 37 

CHAPTER II. 

Stmptoms ...-.--.- 36 

Art. I. — Mode of Access - - - - - - 39 

Art. n. — Febrile Symptoms - - - - - - 41 

Sec. 1.— Chills 41 

Sec. 2. — Heat and State of Skin - - - - - 41 

Sec. 3.— Pulse ....... 43 

Art. III. — Thoracic Symptoms - - - - - 44 

Sec. 1. — Respiration - - - - - -44 

Sec. 2.— Cough - - - - . . - 45 

Sec. 3.— Physical Signs - - - - - - 45 

Art. IV. — Cerebro-spinal, or Nervous, Symptoms - - - 45 

Sec. 1. — Headache ...... 46 

Sec. 2. — Pains in the Back and Limbs - - - - 46 

Sec. 3.— Mind ....... 4G 

Sec. 4. — Physiognomy - - - - - -49 

Sec. 5. — Somnolence ...... 49 

Sec. 6. — Vigilance - - . - - - 49 
Sec. 7. — Senses .......50 

Sec. 8. — Muscles - - - - . - - 51 

Art. V. — Digestive, and Abdominal Symptoms - - - 52 

Sec. 1. — Tongue and Mouth ..... 53 

Sec. 2. — Appetite and Thirst ..... 54 

Sec. 3. — Nausea and Vomiting • - - - .54 

Sec. 4. — State of Bowels ...... 55 



xu 



CONTENTS. 






PAGE 


Sec. 5. — \bdominal Pains 


56 


Sec. 6. — Tympanites 


57 


Abt. YL — ^^Bscellaneoiis Symptoms - 


55 


Sec. 1. — ^Eraaciation 


55 


Sec 2. — State of the Urine 


55 


Sec 3. — ^Epistaxis - - - . 


59 


Sec. 4. — Cutaneous Eruptions 


59 


Sec. 5.— Eschars . . - ■ 


61 


CH.\PTER HL 





.yATOXTCAL L£SIO]!rS _-..--- 

Aet. L — Lesions of the CircalatoTy Apparatus ... 

Sec 1. — ^Heart and Aorta -.--.. 

Sec 2. — State of the Blood . . . . . 

Art. n. — Lesions of the Respiratory Appaiatas 

Sec 1. — Lungs --..-.. 

Sec 2. — Bronchias, Epiglottis, &c. - - - . . 

Aht. TTT- — Lesions of the Brain and its Membranes ... 
Abt. rV. — ^Lesions of the Digestive and Abdominal Organs 

Sec 1. — ^Pharynx and (Esophagus .... 

Sec. 2. — Stomach - - - 

Sec 3. — Small Intestines ------ 

Sec 4. — ^Large Intestines ------ 

Sec 5. — ^Lymphatic Glands . . - . . 

Sec 6. — ^Spleen -.-.... 

Sec 7. — Liver --..... 

Sec. 8. — Pancreas; SauTary Glancls: Urinary Apparatus; and 
Sexual Organs ------ 

Abt. V. — General Remarks -.-... 



63 
63 
63 
65 
66 
66 
66 
67 
68 
65 
6S 
70 



79 
80 



CHAPTER lY. 



CArsxs. 



Sec 1. — ^Locality - _ _ 

Sec 2. — Season - - - - 

Sec 3. — Contagion - - - 
Sec 4. — Exemption from Second Attacks 
Sec 5. — ^Epidemic Influences 

Sec 6. — Age - - - . 

Sec 7. — Sex - - . . 

Sec. 8. — ^Race - - . - 

Sec 9. — Occupation - . . 
Sec 10. — ^Recency of Residence - 
Sec 11.— FUth, Crowding, &c 
Sec. 12. — Exposure; Excesses, &c. 



83 

94 

95 

98 

99 

100 

101 

102 

102 

102 

103 

103 



CHAPTER V. 



Tabit.ttx= aist) Fob?is 



104 




CONTENTS. 



CHAPTER VI. 



Duration, Maiich, akd Complications. 
Art. I. — Duration 
Art. II. — March and Complications 
Art. III. — Peritonitis - - - 

Art. IV. — Relapses 
Art. V. — Sequelce . - . 



XllI 



pags 

109 
110 
lU 
112 
113 



CHAPTER Vn. 



Mortality axd Prognosis 



114 



CHAPTER Vni. 



Diagnosis 



122 



CHAPTER IX. 



Theory 



134 



CHAPTER X. 



Treatment . . - - 

Art. I. — Dr. Jackson's Metliod 
Art. II. — Dr. Nathan Smith's Method 
Art. III. — Chomel's Method - 
Art. IV. — Louis's Method 
Art. V. — Bouillaud's i\Iethod 
Art. VI. — De Larroque's jNIethod 
Art. VII. — Miscellaneous 



142 
143 

146 
149 
154 
157 
158 
159 



CHAPTER XI. 



Definition 



162 



CHAPTER XII. 



Bibliography 



165 



x\v 



CONTENTS. 



PART II. 
TYPHUS FEVER. 



CHAPTER I. 



PRELIMIXAKT MaTTERS 

Art. I. — Introductory 

Art. II. — Names of the Disease 



PAGE 

171 
171 
173 



CHAPTER 11. 



Symptoms ------ 

Art. I. — Mode of Access 
Art. II. — Febrile Symptoms 

Sec. 1.— Chills ... - 

Sec. 2. — Heat and State of Skin 

Sec. 3.— Pulse - . - . 

Art. III. — Thoracic Symptoms 
Art. IV. — Cerebro-Spinal, or Nervous, Symptoms 

Sec. 1. — Headache, Pains in Back and Limbs 

Sec. 2.— Mind .... 

Sec. 3. — Physiognomy - - - 

Sec. 4.- — Senses - - . . 

Sec. 5. — MiTScles - - - . 

Art. V. — Digestive and Abdominal Symptoms 

Sec. 1. — Tongue and Mouth 

Sec. 2. — Appetite .... 

Sec. 3. — Nausea and Vomiting 

Sec. 4. — State of Bowels - - 

Art. VI. — Miscellaneous Symptoms 

Sec. 1 . — ^Emaciation ... 

Sec. 2. — State of the Urine 

Sec. 3. — Epistaxis - - - - 

Sec. 4. — Cutaneous Eruptions 

Sec. 5. — Eschars - . - . 

Sec. 6.— State of the Blood 



174 
174 
175 
175 
175 
177 
178 
179 
179 
180 
182 
183 
183 
184 
184 
185 
185 
186 
188 
188 
188 
188 
189 
192 
192 



CHAPTER III. 

Anatomical Lesions 

Art. I.- — Lesions of the Thoracic Organs 

Sec. 1. — Lungs ... 

Sec. 2. — Heart and Blood 
Art. II. — Lesions of the Brain 
Art, III. — Lesions of the Abdominal Organs 

Sec. 1. — Stomach - - - 



194 
195 
195 
196 
197 
198 
198 



CONTENTS. 



XV 



Sec. 2. — Intestines 
Sec. 3. — Miscellaneous 
Sec. 4. — General Remarks 



PACK 

198 
201 
202 



Causes 



CHAPTER IV. 






- 203 


Sec. 1. — Locality ..... 


- 203 


Sec. 2. — Season, Weather, &c. - 


- 207 


Sec. 3. — Contagion . . . . . 


- 208 


Sec. 4. — Epidemic Influences . . . . 


- 214 


Sec. 5. — Crowding; Filth ; Famine, &c. 


. 215 


Sec. 6.— Age ...... 


- 217 


Sec. 7.— Sex ...... 


- 218 


Sec. 8. — Recency of Residence 


. 219 


CHAPTER V. 





Varieties and Forms 



220 



CHAPTER VL 



Duration and March 

Sec. 1. — Duration - 
Sec. 2.— Crises 
Sec. 3. — Sequelae - 
Sec. 4. — Relapses - 



223 
223 
225 
228 
228 



CHAPTER VII. 



Mortality axd Prognosis 



230 





CHAPTER Vin. 






Diagnosis - 




. 


- 238 


Sec. 1. — Symptoms 






- 239 


Sec. 2. — Lesions - 






. 241 


Sec. 3. — Causes . • 






■ 242 


Sec. 4. — Duration - 






• 243 


Sec. 5.— EjQFects of Remedies 




243 


Sec, 6. — Historical 


CHAPTER IX. 




244 



Theort 



278 



XTl 



CONTENTS. 



CHAPTER X. 



TEXJT?rX5-T - . - - 

Sec. 1. — Bleeding - - - 

Sec. 5. — Puxgsdves 
Sec 3. — ^AfSisions. and Ablutions - 
Sec. 4. — Stitntilants and Tonics 
Sec. 5. — ^Miscellaneous 



PAGE 

280 
280 
284 
2S4 
2S5 
287 



CHAPTER XI. 



DsFismo's 



291 



CHAPTER XII. 



BiBLIO&HAPHX 



293 



PART III. 
PERIODICAL FEVER. 



CHAPTER I. 



PBXLI^riyAET 3IaTTXR5 

Art. I. — Introductory - 

Abt. IL — Xames of the I>isease 



303 
303 
305 



CHAPTER H 

SntPTOxs ...... 

Abt. I — Mode of Access ... 
Abt. IL — Febrile Symptoms - . - 

Sec. 1.— Chills .... 

Sec. 2. — ^Remissions, or Tvpe 
• Sec 3. — State of Surface ... 

Sec. 4. — Heart and Pulse - 
Abt. HL — ThorEicic Symptoms 
Abt. IV. — Cerebxo-Spinal. or Nervous, Symptcms 

Sec. 1. — Headache : Pains in Back and Limbs 

Sec. 2. — Alind .... 

Sec. 3. — Senses, and Physiognomy 

Sec. 4. — 3Iuscular Strength 



306 
306 
307 
307 
308 
311 
312 
313 
313 
313 
314 
315 
315 



CONTENTS. 



XVll 



Art, V. — Digestive, and Abdominal Symptoms 
Sec. 1. — Tongixe and JNIouth 
Sec. 2. — Appetite and Tliirst 
Sec. 3. — Nausea and Vomiting 
Sec. 4. — Epigastrium and Abdomen 
Sec. 5. — Bowels - - - - 

Sec. 6. — Urine ... - 



PAOK 

316 
316 
317 
318 
319 
319 
321 



CHAPTER III. 
Anatomical Lesions .... 

Art. I. — Lesions of the Thoracic Organs 

Sec. 1. — Lungs .... 

Sec. 2. — Heart and Blood 
Art. H. — Lesions of the Cerebro-Spinal Apparatus 

Sec. 1. — Brain and its Envelopes 
Art. hi — Lesions of the Abdominal Organs - 

Sec. 1. — Liver .... 

Sec. 2. — Spleen .... 

Sec. 3. — Stomach - - - - 

Sec. 4. — Intestines 
Art. IV. — General Remarks 

Sec. 1. — Relation of Lesions to Symptoms 

Sec. 2. — Importance, Relative and Absolute 



322 
322 
322 
323 
322 
323 
327 
327 
332 
333 
335 
338 
338 
339 



CHAPTER IV. 



Causes 



Sec. 1. — Locality - 

Sec. 

Sec. 3.— Age 

Sec. 4. — Sex 

Sec. 5. — Race 

Sec. 6. — Exposure ; Excesses, &c. 

Sec. 7. — Malaria 



340 
340 
343 
344 
345 
345 
346 
346 



CHAPTER V. 






Varieties asd Forms 


. 




- 351 


Art. I. — Bilious Remittent Form 


- 




- 351 


Art. II. — Congestive Fever 


. 




- 352 


Sec. 1. — Names 


. 




- 352 


Sec. 2.— Type, and JMode of Attack 




- 353 


Sec. 3. — Varieties; Comatose 


- 




- 354 


Sec. 4. — Delirious Variety 


. 




- 355 


Sec. 5. — Algid Variety 


. 




- 356 


Sec. 6. — Gastro-Enteric Variety 


- 




- 358 


Art. III. — Intermittent Fever 


- 




- 359 


2 









j^^jjj CO^TTESTS. 



CHAPTER VL 



5^r- 1. — 7* ^°'^'^^^^''* " ' . . - - 3o2 

See. 2.— Mkwli 362 

SeEL 3.— CiftiEal D8^s 365 

Sec C— Bdlapses ------- 365 

See. 5. — Seq^Ss ._-.--- 355 



CHAPTER IS. 

Iszc-T - - - - - - - - - 378 

CHAPTER X. 

J»n,TWj.:s^ - - 382 

Abt.L— El&WBBeni-r- leTer ..... 38a 

5.: I _?r=!f=:L-:: .--..- 382 



384 
386 
386 






CONTENTS. 



XIX 



PART IV. 

YELLOW FEVER. 

CHAPTER I. 



Preliminary Matters 

Sec. 1. — Introductory 

Sec. 2. — Names of the Disease 



PAGE 

409 
409 
410 



CHAPTER n. 



Stmptoms ...--- 

Art. I. — ]\Iocle and Period of Access 

Art. n. — Febrile Symptoms - - - 

Sec. 1.— Chills .... 

Sec. 2. — State of Surface: Sweats - 

Sec. 3.— Pulse .... 
Art. ni. — Digestive and Abdominal Symptoms 

Sec. 1. — Tongue and Mouth 

Sec. 2. — Appetite and Thirst 

Sec. 3. — Nausea and Vomiting 

Sec. 4. — Bowels ; Abdomen ; Epigastrium 

Sec. 5. — Urine .... 
Art. IV. — Cerebro-Spinal, or Nervous, Symptoms 

Sec. 1. — Headache, and other Local Pains 

Sec. 2.— State of ]Mind 

Sec. 3. — Physiognomy 

Sec. 4. — Strength; Muscles; Senses 
Art. V. — Miscellaneous Symptoms 

Sec. 1. — Color of Skin 

Sec. 2. — Hemorrhages 

Sec. 3. — Chest 



411 
411 
413 
413 
413 
414 
417 
417 
417 
418 
420 
421 
421 
421 
423 
424 
426 
428 
428 
429 
430 



CHAPTER III. 
AxATOMiCAL Lesions .... 

Art. I. — Lesions of Lungs, Heart, and Blood - 

Sec. 1. — Lungs .... 

Sec. 2. — Heart .... 

Sec, 3.— Blood .... 
Art. II. — Lesions of the Cerebro-Spinal Apparatus 
Art. III. — Lesions of the Abdominal Organs - 

Sec. 1. — Stomach . . - - 

Sec. 2. — Intestines ... 

Sec. 3. — Liver .... 

Sec. 4. — Gall-Biadder and its Contents 



431 
431 
431 
432 
432 
434 
434 
434 
437 
438 
443 



XX 



CONTENTS. 



Sec. 5.— Spleen; Mesenteric Glands; Urinary Organs 
Aht. IV. — Miscellaneous Lesions - - . 

Art. V. — General Remarks - - - - 

Sec. 1. — Relation between Symptoms and Lesions 
Sec. 2. — Causes of Death . - - - 



PAGE 

445 
445 
445 
445 
447 



CHAPTER IV. 



Causes 



Sec. 1. — Locality - - - - • 

Sec. 2. — Season - - - - • 

Sec. 3. — Temperature and "Weather 
Sec. 4. — Age . . - - . 

Sec. 5.— Sex 

Sec. 6. — Race . . - - . 

Sec. 7. — Constitution - - . . 

Sec. 8. — Occupation . . - . 

Sec. 9, — Acclimation - - . . 

Sec. 10. — Exemption from Subsequent Attacks 
Sec. 11. — Epidemiclnfluences 
Sec. 12. — Sporadic . . . . 

Sec. 13.— Marsh Miasmata - - - 

Sec. 14. — Decaying Animal and Vegetable Matter 
Sec, 15. — Contagion . . . . 

Sec. 16. — Exposure ; Fatigue ; Excesses, &c. 
Sec. 17. — Essential Poison 



449 
449 
453 
454 
456 
456 
458 
459 
460 
460 
462 
464 
465 
466 
467 
469 
478 
480 



CHAPTER V. 



Vabieties anb Forms . . - - - 


- 481 


Sec. 1. — Season and Locality - . - 


- 481 


Sec. 2. — Forms, or Grades - - - 


- 482 


CHAPTER VI. 




March xisd Duration - . - - - 


- 486 


Sec. 1.— March, or Type - - - - 


486 


Sec. 2.— Stages 


- 489 


Sec. 3. — Duration - - - - - 


- 491 


Sec. 4. — Convalescence . . - - 


- 491 


Sec. 5. — Relapses - - - - - 


- 493 


Sec. 6. — Sequelae - - . - - 


- 493 


Sec. 7. — Period of Incubation . - - 


- 493 


CHAPTER VII. 





Mortality aijd Prognosis 



494 



CONTENTS. 
CHAPTER VIII. 



XXI 



Diagnosis 



PAGE 

500 



Theory 



CHAPTER IX. 



603 



CHAPTER X. 



Treatment . . . - . 

Sec. 1. — Preliminary- 
Sec. 2. — Mercurials 
Sec. 3. — Antiphlogistic Method 
Sec. 4. — Cinchona ; Tonics and Stimulants 
Sec. 5. — Purgatives 
Sec. 6. — Spanish INIetliod - 
Sec. 7. — Mobile Method - 
Sec. 8. — Prophylactics 
Sec. 9. — Conclusion 



505 
505 
506 
508 
5U 
511 
511 
512 
513 
514 



CHAPTER XL 



Definition 



516 



CHAPTER XII. 



Bibliography 



618 



PART FIRST. 

THE 

HISTORY, DIAGNOSIS, AND TREATMENT 

OF 

TYPHOID FEVER. 



TREATISE ON FEVERS 



PART I. 
TYPHOID FEVER. 

CHAPTER I. 

PRELIMINARY MATTERS. 
ARTICLE I. 

INTRODUCTORY. 

In writing a history of the fevers of the United States, I begin 
with that of Typhoid Fever, for three reasons. 

In the first place, my own knowledge of the disease, derived 
from personal observation, is much more extensive than of the 
other forms of fever. My attention was early and strongly called 
to its investigation by the remarkable work of Louis upon the 
same disease, as it shows itself in Paris. My professional life, 
thus far, has been mostly passed in the midst of a population, 
especially exposed to some of its predisposing causes, and 
amongst whom, it has, very constantly, and at times very exten- 
sively, prevailed ; so that a personal acquaintance with this fever 
of twenty years' continuance has given me sufficient opportunity 
to become somewhat familiar with its character ; more so, at any 
rate, than with the remaining diseases, which I propose to describe. 

In the second place, there is good reason to think, that typhoid 
fever is more generally and extensively prevalent, in various parts 
of the world, than the other distinct forms of essential or idiopathic 
fever. This is a point which requires further and more accurate 
observation for its settlement ; but it is pretty certainly true of the 
3 



34 TYPHOID FEVER. 

temperate latitudes of Europe, and America. The actual extent 
of its prevalence will be more fully spoken of hereafter. 

In the third place, typhoid fever has been more minutely, more 
accurately, more thoroughly studied, than any other distinct form 
of essential or idiopathic fever. Although a complex, and in many 
respects, an obscure disease, its diagnosis is, in most cases, easily 
and positively made out. Its natural history has been very fully 
investigated, and the results of this investigation faithfully recorded 
and summed up. Its symptoms, its lesions, its causes, so far as 
these latter are appreciable, have been very exactly ascertained 
and settled ; and they have been very patiently compared with 
the symptoms, the lesions, and the causes of other diseases. This 
more complete knowledge of the disease renders it a very conve- 
nient starting point, and an exceedingly valuable standard of 
comparison, in our subsequent study of other forms of fever, more 
or less related to this, but whose history and character have not 
been so definitively and precisely established. These, very briefly, 
are the simple and obvious considerations which induce me to 
commence this history with a description of typhoid fever. 



ARTICLE II. 

NAMES OF THE DISEASE. 

I have adopted the term typlioid fever as the name of this dis- 
ease, simply because it is not particularly objectionable, and 
because it seems to be coming into general use. It is that which 
is most commonly given to the disease by the French, although 
many of their writers have coined other, and as they think, more 
appropriate appellations. Petit and Serres described it in 1813, 
under the name of entero-mesenteric fever. This term, as has 
been observed by Andral, has the advantage of marking the pe- 
culiar lesion of the disease, while it is free from the objection of 
pre-judging, by any implication, its nature or character. Bre- 
tonneau calls it a dothinenterite, from the pustular inflammation 
of the intestine. Cruveilhier and others have applied to it the 
name of follicular enteritis. Bouillaud has called it typhoid-enter o- 
mesenteritis. By the Germans it is commonly called abdominal 
typhus. By some German writers it is called nervous fever, or 
gastric nervous fever ; by some it is called intestinal ulcerating 



NAMES OF THE DISEASE. 35 

typhus^ or typhous suppuration of the intestines; by others, typhus 
gangliariSj and so on.' In New England, it has generally been 
known under the name of typhus, or typhous, fever ; and by the 
great majority of practitioners it still continues to be so designated. 
Since, however, it has been ascertained, that the disease differs, 
in many important respects, from the typhus of British writers, it 
has become manifestly necessary to apply to it some other appel- 
lation, and in conformity to the example of Louis, Gerhard, Jack- 
son, and others, I have chosen that of typhoid fever. 

It may be well to say a ^vord here in regard to the identity of 
the continued fever of New England with the typhoid fever of the 
French pathologists. This identity is very clearly and positively 
settled. No one familiar \vith the disease, as it shows itself in 
Paris, and as it is described by Louis, Chomel, and Andral, and 
who reads Nathan Smith's description of the typhous fever of New 
England, can doubt for a moment, so far as the symptomatology is 
concerned, that such is the case. The identity of the pathological 
lesions in the fever of the two countries has been more recently 
established. Dr. E. Hale, Jr., of Boston, published in the Medi- 
cal Magazine for December, 1833, an account of three dissections 
of persons, considered by him to have died with this disease. If 
the diagnosis in these cases could be looked upon as certain and 
positive, they would constitute, so far as I know, the first published 
examples of the intestinal lesion of the disease, as it occurs in 
New England. The diagnosis, how^ever, in all the instances, 
must be regarded as somewhat doubtful, and the alteration of the 
intestinal follicles does not seem to have been very clearly or 
strongly marked. The first authentic and unequivocal cases on 
record, that I have been able to find, are two, which were pub- 
lished by Dr. Gerhard, in the American Journal of Medical Sci- 
ences, for February, 1835. In the Medical Magazine for June, 
1835, I gave a short account of the entero-mesenteric alterations 
in five cases of unequivocal typhoid fever, w^hich alterations cor- 
responded exactly to those described by Louis. I have upon my 
note book the anatomical history of two similar cases, which oc- 
curred during the months of January and February, 1833, but 
which were never published. Dr. James Jackson, Jr., then a medi- 
cal student, observed the intestinal lesion in a clear case of the dis- 
ease as early as October, 1830, although the account of the ob- 

* Edin. Med. and Surg. Journ.j vol. xlviii. p. 145. 



36 TYPHOID FEVER. 

servation was not made public till 1835.^ Dr. Jackson, Jr., after 
having studied typhoid fever in Paris, aided and guided by the 
personal instructions of Louis, again saw the disease in Boston ; 
and in two cases, one of which occurred in 1833, and the other 
in 1834, he found the characteristic lesion of the intestinal fol- 
licles and mesenteric glands. An account of these observations 
was published in 1835. Dr. Jackson, Sen., in his Report on 
Typhoid Fever, communicated to the Massachusetts Medical So- 
ciety in June, 1838, says, that the alteration of Peyer's glands 
had been noticed at the Massachusetts General Hospital, previous 
to 1833, in cases which were carefully examined. Since the 
periods above referred to, more extensive and accurate observa- 
tions, by Dr. J. Jackson, Dr. Hale, Dr. Bigelow, Dr. Bowditch, 
Dr. J. B. S. Jackson, Dr. Shattuck, Jr., Dr. Holmes, and others 
of Boston ; and by Dr. Gerhard and Dr. Stewardson of Philadel- 
phia, Dr. Swett of New York, and others, have uniformly sus- 
tained the correctness of the^e early conclusions, and demonstrated 
the entire identity of the typhoid fever of Paris and of the United 
States. 

ARTICLE m. 

HISTORY. 

By the history of t}"phoid fever, here, I mean what may be 
called its literary history, — an account of the successive investi- 
gations which have led to our actual knowledge of the disease. 
In order to render this at all full and complete, it would be ne- 
cessary to go into the history of the entire subject of continued 
fever, a subject more extensive and more complicated perhaps 
than any other in the domain of medical science. Neither the 
design nor the character of my book renders it necessary that I 
should do this ; I shall content myself with touching simply a few 
of the more salient points of this history. 

The character of typhoid fever, — its symptoms, its lesions, its 
causes, and so on, — was first fully and carefully studied by the 
physicians of the continent of Europe. We are hardly at all in- 
debted to British observers for our knowledge of this particular 
form of disease. The first description of its pathological lesions, 

^ ^'lemoir of James Jackson, Jr^ p. 222, et seq. 



HISTORY.— METHODS OF DESCRIPTION. 37 

at all complete and satisfactory, Avas contained in the work of 
Prost, published in 1804. Some years subsequent to this, Brous- 
sais succeeded in establishing his brilliant and powerful but 
transitory dynasty, and under its tyrannous domination, the study 
of continued fever, on the continent, was cramped and misdirected, 
instead of being properly guided, favored, and advanced. Every- 
thing gave way to the bold effrontery of the dogma, that all fevers 
are dependent upon local inflammations. In looking back now 
upon the career and achievements of Broussais, it is astonishing 
to see with what meek alacrity our science put on and wore the 
yoke which he fitted to her neck. The exclusive and hypothetical 
views of Broussais were controverted ably, and at length success- 
fully by Andral, Chorael, and other pathologists; but it is to the 
great work of Louis that we are indebted for the first complete 
and comprehensive description of typhoid fever, — a description 
so complete, and so comprehensive, that the labors of subsequent 
observers have hardly added to its materials or modified its pro- 
portions to any appreciable extent. Amongst other continental 
observers who studied particularly the intestinal lesions of the dis- 
ease, were Roederer and Wagler, Petit and Serres, and Bretonneau. 
The original researches of Louis and Chomel were confined to the 
disease as it shows itself in the adult ; within the last few years 
the typhoid fever of children has been carefully studied, especially 
by Barthez and Rilliet, and by Taupin. Dr. Richard Bright has 
given, amongst his very splendid pathological illustrations, some 
excellent specimens of the intestinal ulcerations of this disease. 
The most important publications upon the subject made in this 
country, are those of Nathan Smith, Dr. James Jackson, and Dr. 
E. Hale, of Boston, and Dr. W. W. Gerhard, of Philadelphia. 



ARTICLE IV. 

METHODS OF DESCRIPTION. 

There are two methods, either of which may be adopted, in the 
description of a disease. One of these, and that which, with a 
few exceptions, has been in universal use from the time of Hip- 
pocrates to the era of Louis, consists in a general enumeration of 
the more striking and obvious phenomena of the disease, in their 
various combinations and progress, constituting a kind of portrait, 



38 TYPHOID FEVER. 

or picture. The other, which has been followed by many writers 
within the last fifteen years, especially amongst the French, con- 
sists, not merely in this general enumeration of the phenomena, 
their combinations and progress ; but in a thorough and careful 
analysis of these phenomena ; in a special and particular study of 
each individual element, which goes to make up the disease; and 
in a strict estimate of the relative value and importance of each 
and all of these several elements. This analytical process, this 
"searching operation," is applied in study as well as in descrip- 
tion, not only to the symptoms of a disease, but, to a considerable 
extent, also, to its pathology, etiology and therapeutics. Amongst 
the best examples of the first method, — the physiognomical por- 
traiture of disease, — may be mentioned Sydenham's description 
of measles and St. Vitus's dance, and Dr. Ware's description of 
delirium tremens. The first and one of the most perfect examples 
of the latter is to be found in Louis's Researches upon Phthisis, 
published in 1825. 

Each of these methods has its advantages and its disadvan- 
tages, its excellencies and its defects. By the first, a more com- 
plete and integral picture of the disease is presented, at once, to 
the mind, than can be done by the second. We are enabled to 
see, at a single glance, the form, the outlines, the features, the 
physiognomy of the disease. But in many very important par- 
ticulars, this method is inferior to the second. It is merely a 
picture of disease ; like all other pictures, more or less like the 
original, strongly or feebly colored, according to the peculiar taste 
or ability of the individual artist. It is necessarily wanting in the 
scientific accuracy of which the second is susceptible. It is less 
complete, less perfect. The disadvantages of the latter, consist 
in the absence of that wholeness and unity of impression, which 
are made by the former. The mind, in order to get at the inte- 
gral and entire picture, must arrange and combine the scattered 
materials, which it has studied separately. As one of the leading 
purposes of the present work is to point out, as far as our actual 
knowledge will enable us to do so, the characteristic features of 
each of the four great forms of idiopathic fever; to establish, as 
far as possible, a clear and positive diagnosis ; to ascertain the 
resemblances and the diflferences between them ; I shall rely almost 
exclusively upon the last mentioned method, as the only one capa- 
ble of leading to these results. 



39 



CHAPTER 11. 

SYMPTOMS. 
ARTICLE I. 

MODE OF ACCESS. 

There is a good deal of difference, in different cases of typhoid 
fever, so far as the suddenness or violence of the seizure is con- 
cerned. There is no other acute disease, perhaps, in which the 
attack is more frequently slow and gradual than in this. In many 
cases, it is quite impossible for the patient to fix with any accu- 
racy upon the day when his fever commenced. Neither, in many 
of these same cases, is he able to tell m what his sickness con- 
sisted. He can only say that, for several days, he has not en- 
joyed his accustomed degree of health. He may have merely felt 
a sensation of mental and bodily languor, an indisposition, or an 
inability to accomplish his usual labor, either of mind or body. He 
may have had slight and dull pain in the head, or in the back 
and limbs, with a general feeling of soreness or of fatigue. At 
the same time he may have experienced some sensations of chilli- 
ness, alternating with heat. There may have been, also, diminu- 
tion, or loss of appetite, and moderate thirst, with a dry or clammy 
state of the mouth. The expression of the countenance some- 
times becomes listless and dull, the eye loses its animation, and 
the mind is either indifferent or apprehensive. There may have 
been moderate diarrhoea, with some pains in the abdomen. This 
obscure and indefinite condition of ill health may continue for 
more than a week, occasionally for two or three weeks even, with 
but slight changes from day to day. Oftentimes there is a slow 
but steady increase in the severity of these morbid sensations, 
with a like gradual but regular appearance of other and more 
characteristic symptoms of the disease, — these latter coming out, 
day by day, one after another, a complete and successive deve- 



40 TYPHOID FEVER. 

lopment of the peculiar and strongly marked phenomena of the 
disease. In other cases, after an indefinite continuance of this 
obscure precursory period, there is a sudden supervention of the 
more violent symptoms. Nathan Smith says, — "the disease 
attacks in such a gradual manner, that we hardly know on what 
day to fix its commencement."^ Dr. James Jackson says, — 
" there is more difficulty, perhaps, in ascertaining the commence- 
ment in cases of typhoid fever, than in many other acute dis- 
eases."^ 

In a certain proportion of cases, however, precisely how large, 
I am not able to say, the access of the fever is more violent, and 
its period much more distinctly marked. Chomel, indeed, says, 
that most frequently the invasion is sudden, coming on in the 
midst of perfect health, unexpectedly, and not preceded by any 
precursory symptoms. Of one hundred and twelve cases, in 
which this point was exactly observed, the access w^as sudden in 
seventy-three ; in the others, there were obscure, premonitory symp- 
toms.^ Forget thinks the gradual access of the disease is more 
common than is indicated by these statistics. And this opinion 
agrees w4th my own observation. I am sure that, in a large pro- 
portion of cases, in private practice, the disease is slow and 
gradual in its approaches. It will be at once seen that this ques- 
tion can be more readily settled in private than in hospital prac- 
tice. The mode of attack, in these cases, is various; most fre- 
quently, perhaps, by a chill, accompanied by debility and headache, 
and followed by heat and thirst. In other cases, the mode of 
attack is diflferent. During a grave epidemic of typhoid fever, 
which prevailed in the city of Lowell, in the winter of 1834-5, I 
saw two cases, in which the first feelings of ill health, experienced 
by the patients, so far as could be ascertained from them, consisted 
of severe, griping pains in the bowels, accompanied with tender- 
ness on pressure. In these cases, diarrhoea was an early and 
prominent symptom. In another, and that a fatal case, the patient 
had been at her usual work during the day, and on getting into bed 
at night felt lame, this being the first feeling of sickness of which 
she was conscious. But, w^hateverbe the mode of attack, whether 
this be slow, insidious, creeping and obscure, marked by no obvi- 

> A Practical Essay on Typhus Fever. By Nathan Smith, M. D. 

2 Report on the Typhoid Fever. By James Jackson, M. D. 

3 Le9ons de CUnique Medicale, Chomel, p. 4. 



SYMPTOMS.— CHILLS.— STATE OF SKI 

ous and prominent symptoms, or, on the other hand, sudden and 
violent, — in either case, the disease goes on, for a considerable 
period of time, varying, of course, according to its severity, and 
its favorable or fatal termination ; during which progress it is 
charactei'ized by a greater number and variety of symptoms ; in 
themselves, in their combinations, and their successive appear- 
ance, peculiar to this fever, than are to be found in any other form of 
acute disease. These several symptoms, classified and arranged, 
I now proceed to describe, as fully and faithfully as the present 
state of our knowledge will enable me to do. 

ARTICLE II. 

FEBRILE SYMPTOMS. 

Sec. I. — Chills. Like most acute diseases, typhoid fever is at- 
tended by chills or rigors. These are, generally, not very severe. 
Dr. Jackson says, that in the Massachusetts General Hospital, 
rigors were much less frequent than chills. Nathan Smith ob- 
serves, merely, that in the commencement there is, generally, 
some degree of chilliness felt by the patient. Of thirty-three fatal 
cases, cited by Louis, thirty-one had chills ; in one-fourth of 
which number they were severe, accompanied with trembling. 
Of forty-five grave cases, recovered, all were marked by chills, 
excepting three ; and of thirty-one mild cases, there were chills 
in twenty-four. 

This symptom, in a great majority of instances, is present at 
the commencement, or very early in the disease. It is one of the 
most constant atteridants upon the formal access of the fever. The 
chill occurs oftenest in the course of the day, and in a large pro- 
portion of cases is repeated, more or less frequently, during the 
early period of the disease. It is not less constantly present in 
cases amongst children, than it is amongst adults. 

Sec. II. — Heat and State of the Skin, Following the chill or 
rigor, and in the intervals, w^hen these are repeated, there is, 
almost always, increased heat of the skin. This heat varies very 
much in different respects. In many patients, it is quite moderate 
in degree, and pretty uniformly diffused over the body. In others, 
the morbid heat is high and burning, and not unfrequently very 



42 ' TYPHOID FEVER. 

unequally distributed. Nathan Smith says, — " sometimes, the 
head and trunk will be excessively hot, while the extremities are 
cooler than natural; at others, the extremities will be preternatu- 
rally hot, when the body is but moderately so. One cheek will 
often appear of a deep red color and be very hot, while the other 
remains pale and cool; as its color and heat subside, they seem 
to cross over and affect the opposite cheek in the same manner. 
This color and heat usually extend so far as to include the ear of 
the affected side." In the latter stage of grave and fatal cases, 
the intensity of the morbid heat frequently diminishes ; and in 
mild cases, it is not often very high, even in their early periods. 

This morbid heat, as one of the elements of the exacerbations, 
or fever fits, is subject to certain variations in the course of each 
day. In grave cases, these are of very constant daily occurrence. 
Sometimes they are irregular in their appearance, coming on at 
different and uncertain times of the day, although more commonly 
there are two each day. In the early period of the disease, the 
most strongly marked exacerbation is usually in the afternoon. 
During these fever fits, there is increased redness of the cheeks, 
acceleration of the pulse, and a general aggravation of the severity 
of all the uncomfortable and painful sensations. Dr. Jackson re- 
marks, that these exacerbations are much more common in some 
years than in others.^ 

The state of the skin, in regard to dryness and moisture, is 
quite different in different patients. In a small proportion of 
severe cases, the skin is almost constantly dry, during the whole 
course of the fever. In others, there is more or less moisture. 
Sometimes the sweats are limited to a short period following the 
evening exacerbation, or they break out in the night, during sleep. 
Not unfrequently they are profuse, sometimes confined to certain 
portions of the body, at oihers extending over the whole surface. 
Chomel says, that they often exhibit a strong acid odor. Louis 
observes, that the sweats are in no degree proportionate to the 
morbid heat, and that not unfrequently they are prolonged during 
convalescence, preventing the re-establishment of the strength, 
and resisting the influence of aromatics and bitters. Nathan Smith 
speaks of " what has been called the washer-woman'' s sweat, which 
is extremely profuse over the whole surface of the body and ex 

' Report, &c. p. 135. 



SYMPTOMS.—PULSE. 43 

tremities ; standing in large drops on the face, and giving to the 
cuticle, on the palms of the hands and soles of the feet, a corru- 
gated appearance and a light color, as if it had been long mace- 
rated in water. In such cases, the perspiration is warm, till a 
short time before the patient expires." He never saw an instance 
of recovery after this kind of sweating. 

Dr. Smith says, also, — "there is a remarkable odor arising from 
a person affected by this disease, so peculiar that I feel assured 
that upon entering a room, blindfolded, where a person had been 
confined for some length of time, I should be able to distinguish 
it from all other febrile affections." My own experience, in this 
matter, coincides with that of Dr. Smith. This odor, which is 
not pungent and ammoniacal, like that which is said to arise from 
the bodies of patients with the grave forms of the British typhus? 
but of a semi-cadaverous and musty character, I have frequently 
noticed, especially during the late stages of severe and fatal cases. 

After recovery, when the case has been one of considerable 
severity, the cuticle often peels off, in large flakes, from the palms 
of the hands and the soles of the feet; the hair, also, frequently 
falls off from the head, and is succeeded by a new growth.^ 

Sec. III. — Pulse. The circulation is nearly always accelerated ; 
and, in many cases, otherwise modified. The frequency of the 
pulse, during the whole course of the disease, may be said to 
range between 70 and 140 in the minute. As a general rule, the 
frequency of the pulse is in proportion to the severity and danger 
of the disease. The pulse is considerably more frequent in female, 
than in male patients. Dr. Jackson's Report contains some in- 
teresting results in regard to this subject. He found, that in the 
cases which terminated favorably, the average, least frequent 
pulse was 74.16, and the average, most frequent pulse, 102.68: 
while in the cases, w^hich terminated fatally, the average, least 
frequent pulse was 91.88, and the average, most frequent pulse 
was 129.29. Amongst the fatal cases, in the males, the average, 
least frequent pulse was 85.50, the average, most frequent pulse, 
124.29 ; while amongst the fatal cases, in the females, the average, 
least frequent pulse w^as 106.64, and the average, most frequent 
pulse, 138.58. With the establishment of convalescence, the 

* Nathan Smith. On Typhous Fever. 



44 TYPHOID FEVER. 

pulse, generally, though not always, approaches its healthy 
standard of frequency. 

The other variations in the character of the pulse, are not sus- 
ceptible of such definite statement, as those of its frequency, but 
they are still, in many cases, very obvious. Sometimes, especially 
in mild cases, where the circulation is only moderately accelerated, 
the pulse preserves its natural softness and volume. This is 
never the case where it is very frequent. The pulse is then some- 
times sharp and jerky, generally small, and pretty easily com- 
pressed, and not unfrequently, undulating, or his-feriens. 

Distinct intermissions and irregularity of the pulse are not very 
common, although they occur in a moderate proportion of very 
grave and fatal cases. Louis thinks that this modification of the 
pulse is generally connected with a secondary affection of the 
heart. 

ARTICLE IIL 

THORACIC SYMPTOMS. 

Sec. L — Respiration. Modifications in the character of the 
respiration are not often mentioned amongst the phenomena of 
typhoid fever; but they are of pretty frequent occurrence, and 
some of them are deserving of particular notice. The most com- 
mon alteration of the breathing consists simply in the usual ac- 
celeration, which accompanies febrile excitement. Under certain 
circumstances, however, there is a more marked and peculiar 
change in the character of the breathing. In high grades of the 
disease, and particularly in its later stages, accompanied, inva- 
riably, or nearly so, by delirium or stupor, the respiration becomes 
irregular, noisy, and hissing. Nathan Smith speaks particularly 
of this peculiarity of the breathing. He says, — " after the 
patient has been some time sick, if the disease proves severe, 
there is a peculiar whistling sound produced when he breathes 
through the nose ; and when asleep, or lying in a state of coma, 
the mouth is generally kept open, and the breathing has some- 
what of a stertorous sound." I do not think that this irregular, 
noisy, sibilant respiration depends, in any degree, upon disease of 
the lungs. It is, manifestly, connected with and dependent upon 
a morbid condition of the brain. 



SYMPTOMS.— RESPIRATION— COUGH— PHYSICAL SIGNS. 45 

Positive dyspnoea is not very common. It occurs, of course, 
where there is extensive secondary disease of the kings, and 
sometimes it is occasioned by excessive tympanitic distention of 
the abdominal parietes. 

Sec. II. — Cough. Typhoid fever, in a large majority of cases, 
is attended by cough. This is generally slight, and hardly at- 
tracts the attention of the physician or the patient. According to 
Louis, it most commonly commences between the fifth and the 
fifteenth day of the disease. The sputa are usually small in 
quantity, sometimes tenacious and colorless, sometimes bloody, 
simply from an admixture with blood from the nares, and some- 
times rusty from a complication of pneumonitis. 

Sec. III. — Physical Signs. The most constant and character- 
istic of the physical signs, connected with the thoracic organs, 
consists in a dry, sonorous, or sibilant rhonchus. This, in many 
cases, is very loud, and heard universally over the chest ; its ex- 
tent and severity altogether disproportionate to the dyspnoea. 
Louis was the first, I think, who noticed, particularly, this sign in 
typhoid fever. It appears early in the disease. Late in the fever, 
especially near the close of cases about to terminate fatally, there 
is often a circumscribed crepitous rhonchus, wdth other physical 
signs of local, secondary pneumonitis. Occasionally, instead of 
the dry, sonorous or sibilant, there is a humid or mucous 
rhonchus. 



ARTICLE IV. 

CEREBRO-SPINAL, OR NERVOUS, SYMPTOMS. 

Having completed the detail of symptoms, to w^hich the term 
febrile is more particularly applied, and which^ w^ith certain mo- 
difications and peculiarities, are common to all essential fevers, to 
all acute inflammatory diseases of considerable extent or severity, 
and to very many chronic, organic alterations, I now proceed to 
the description of another very extensive group of phenomena, 
consisting in disturbances of the functions of the nervous appara- 
tus. These disturbances occupy a very important place in the 



^ TYPHOID FEVER. 

natural history of typhoid fever, and serve, to a veiy- considerable 
degree, to distinsfuish it from nearly all other forms of disease. 

Sec. I. — Headache. Pain in the head is amongst the most con- 
stant symptoms of the disease. It is, indeed, very rarely absent. 
Louis says, that of eighty-seven cases, in Tvhich the patients re- 
covered, there was headache in all but three. It is as common an 
accompaniment of mild as it is of severe cases. 

This pain is amongst the earliest symptoms. In many cases, 
it is the first thins: which arrests the attention of the patient, and 
marks the formal access of the fever. Chomel says that this 
occurs most frequently on rising in the morning. Sometimes it 
comes on after the third or fourth day. Its duration is various ; 
but, very generally, after a longer or shorter period, it gradually 
diminishes in severity and finally disappears. In severe cases, 
which recovered, Louis found its most common duration to be 
from eight to ten days. 

The character and degree of this pain are various. ]\Icst fre- 
quently, it is dull, heavy, or throbbing, not occupying very much 
the attention of the patient. In a few cases, it is intense and 
acute, occasioning great distress. It is generally continuous, al- 
though its severity may be increased during the febrile exacerba- 
tions. It is less severe in mild, than in grave cases. Xow and 
then, it is the most prominent and importunate symptom during 
the whole course of the disease. It occupies, most frequently, 
perhaps, the forehead and temples, but it often extends over the 
whole head. It is not unfrequently accompanied with some sore- 
ness and stiflSiess of the eyeballs, felt on pressure and on motion. 

This symptom is generally present in children. Taupin says 
that the pain is almost always confined to the frontal resrion. It 
is heavy, and not very acute. 

Sec. n. — Pains in the hack and limbs. In many cases, the 
headache is attended with pains in the back and limbs. These 
pains, I think, are more constant and distressing in the legs than 
in the arms. They go off with the headache, and frequently, 
indeed, before the disappearance of the latter. 

Sec. in. — State of the Mi/id. I have already remarked, in 
speaking of the mode of access of typhoid fever, that one of the 



SYMPTOMS.— STATE OF THE MIND. 47 

earliest and most constant phenomena consists in mental languor 
or inability. The patient is sometimes impatient and irritable, 
but, more frequently, listless and indifferent, or perhaps timid, 
and apprehensive of the danger of the approaching disease. He 
finds it difHcult to fix his attention, or to pursue his accustomed 
train of thought. He is forgetful, and does not measure the lapse 
of time with his usual readiness and accuracy. This condition of 
the mind, in cases of moderate severity, may continue through 
the entire course of the fever, up to the period of convalescence. 
In graver and fatal cases, it is generally lost either in delirium or 
stupor. 

Delirium is a common symptom of typhoid fever. Its fre- 
quency and degree are in pretty direct proportion to the severity 
and danger of the disease. Of forty-six fatal cases, cited by Louis, 
there was delirium in thirty-eight. In tw^o of these, the delirium 
was of short duration ; and in two others, it was present only 
during the last two or three days of life. But it should also be 
remarked, that seven of these cases were fatal from perforation of 
the intestine; and that this accident most frequently occurs in 
cases of moderate severity. I have seen the disease, in its worst 
form, terminating fatally in the course of the second week, with- 
out any delirium, but this is, certainly, not a common occurrence. 
Of Louis's fifty-six grave cases, terminating favorably, thirty- 
nine were marked by delirium; while of thirty-one mild cases, 
there was delirium in only three ; and even in these few, it was 
mild in its character and of short duration. 

In a small number of cases, this symptom is present at the 
commencement, or very early in the disease. Generally, how- 
ever, it comes on in the course of the first or second w^eek of the 
fever. As a general rule, it appears early in proportion to the 
gravity and to the rapid progress of the disease. Its march and 
duration are various. In fatal cases, it rarely disappears, after its 
occurrence, till it is lost either in coma or death. In grave cases, 
which recover, it goes off with the approach or commencement of 
convalescence, its subsidence or diminution constituting one of the 
earliest and surest signs of this desirable event. In many cases, 
especially of a mild or moderate character; and for the first few 
days, after its appearance, even in severe cases, it is present only 
during the night, or in the febrile paroxysm, or, perhaps, for a 
transient period immediately after waking. Under such circum- 



48 TYPHOID FEVER. 

stances, the patient can be called back firom bis incoherent wander- 
ings, and by exciting and holding the attention, his mind kept 
steady and clear. As soon^ howcTcr, as this external excitement 
is "wiAdrawn, the mind at once lapses into its disturbed and irre- 
gular action. 

The delirium is generally of the kind, to«which the terms loWy 
and mutUrmg^ haTe been applied. In many cases, howcYer, and 
especially in sach as are rapid in their march, and of great 
scTcrity, the delirium is attended with wild and violent agitation. 
Sometimes, the patient is in constant and restless motion in his 
bed, picking at his bed clothes, or pulling them about, and fre- 
quenti^y drawing them tightly OTcr his head. Sometimes, he rises 
suddenly fiom his bed, when, if not restrained, he will sit upon 
its side, or wander, aimless and incoherent, for a few moments, 
about the room. In these cases, the agitation is so Tiolent, that 
it requires the constant presence of attendants, and occasionally 
no sli^t degree of force, to keep the patient in his bed. This 
Tiolent delirium is often attended, also, with cries and screams, 
particularly during the night. 

Distinctly monomaniacal debrium is very rare, although it is 
seen, occasionally, after the active period of the disease has gone 
by. Louis alludes to some cases, where, in the midst of the most 
dangerous symptoms, the patients declared, that they were very 
well. He says, that he has never known a patient, under such 
circumstances, to recover. The restoration of the healthy action 
of ihr niLi. on recovery, is more or less gradual, but nearly al- 
ways :; .: .e:e. Nathan Smith says, that in some instances it 
appei:-i :: ':.\m. that the moral principle was affected after re- 
covery. Hr s z : ;- , particularly, of a young man, who, after re- 
covery £::i :- r - : : :- :f the disease, had a strong propensity 
to steal. -^: r: :;: r::r .hefts, some of them from a young man 
to whom he was under great obligations, and who had nursed him 
during his sickness, he was detected and punished. His cha- 
racter before his illness had been good. Dr. Smith says, also, 
that, after recovery, the whole time that has elapsed, and all the 
events that have taken place during the fever, are entirely blotted 
out from the memory, and are never after recovered. This may 
be true to a certain extent, but not without many exceptions and 
qualifications. Louis says, in his second edition, that since the 
publication of his BesearcheSj he has seen three hundred cases of 



SYMPTOMS —PHYSIOGNOMY.— SOMNOLENCE.— VIGILANCE. 49 

typhoid fever, and that in only one was there any morbid con- 
dition of the mind remaining after the establishment of conva- 
lescence. According to Rilliet, delirium rarely shows itself in 
children before the fifteenth day of the disease. 

Sec. IV. — Physiognomy. The expression of the countenance is 
strongly marked and peculiar. Very generally, even in cases of 
moderate severity, it is dull, listless and vacant. The eye is 
heavy and languid. The indifference, sluggishness, and apathy 
of the mind are strongly painted on the face. If there is much 
suffering, either from pain, or, as more commonly happens, from 
the indefinite and indescribable restlessness of fever, the usual 
heavy and stupid expression of the countenance is mixed with or 
supplanted by one of sadness, anxiety, and distress. In many 
very mild cases, there can hardly be said to be any other change 
in the look, than a notable diminution of its animation and quick- 
ness. 

Sec. V. — Somnolence. In most cases, preceding the delirium, 
and often alternating with it after its appearance, there is more 
or less drowsiness or stupor. This symptom makes its appear- 
ance early in proportion to the intensity and to the rapid march 
of the disease. Louis found it present in nine-tenths of his fatal 
cases. When the fever was of a mild character, he noticed it ia 
a little more than half the cases, and in these, it was later in its 
access, slight in degree, and brief in its continuance. In fatal 
cases, it generally persists and increases, after its first appearance, 
unless when interrupted by violent delirium, until it ends in com- 
plete coma, or is lost in death. Where the fever terminates 
favorably, it gradually subsides, and, like the delirium, finally 
disappears with convalescence. 

Dr. Jackson found, that in the Massachusetts General Hospital, 
it occurred in 1 case in 3.81 amongst those which terminated fatall}^, 
and in 1 case in 7.25, only, amongst those which terminated 
favorably. 

Sec VI. — Vigilance. There is an opposite condition, that of 
prolonged and obstinate watchfulness, which is common in typhoid 
fever. This distressing symptom, interrupted, perhaps, occasion- 
ally, by a transient, disturbed, and unrefreshing slumber, is more 
4 



50 TYPHOID FEVER. 

common in the early than in the late periods of the disease, and is 
much more frequently present in grave than in mild cases. It is 
often associated with restlessness or delirium. 

Sec. VII. — State of the Senses. Amongst the alterations in the 
functions of the senses, the most common are dizziness, ringing in 
the ears, and dullness of hearing. The first of these is often felt 
amongst the precursory symptoms, before the patient has taken to 
his bed, and it occurs subsequently, especially on his attempting 
to assume an upright position. Ringing or buzzing sounds in 
the ears are present, mostly in the early or middle period of the 
disease, in a majority of severe cases. In mild cases, they also 
occur, but less frequently. Dullness of hearing was noticed by 
Louis in two-thirds of his fatal cases, and in thirty-three of forty- 
five grave cases, terminating in recovery. It is somewhat less 
common where the fever is moderate. It appears earlier than the 
tinnitus aurium, and is not unfrequently followed by this latter 
sensation. Nathan Smith says, in his description of the disease, — 
" the hearing is often impaired, almost from the commencement 
of the attack. Sometimes, false hearing occurs, and the patient 
imagines he perceives voices and sounds when nothing of the kind 
exists." 

The eyes and their functions are more rarely affected. If there 
is active febrile excitement, there is often increased sensibility to 
light, mostly in the early stage of the disease. In a considerable 
proportion of cases, there is some injection and redness of the 
conjunctiva. This occurs in the later periods of the disease, and 
is commonly accompanied with a viscid secretion, rendering the 
edges of the lids more or less adherent to each other. This state 
of the eyes is particularly spoken of by Dr. Nathan Smith. 

Imperfect and perverted vision occurs occasionally, but it is not 
common. Like the dizziness and ringing in the ears, this not 
unfrequently comes on, temporarily, when the patient sits up in 
his bed. 

The sense of taste, as might be expected from the state of the 
tongue and the loss of appetite, is either dull or perverted. Cho- 
mel speaks of patients who chewed, without repugnance, pills 
composed of medicinal substances, which were very disagreeable 
during health. 

The general cutaneous sensibility is not often affected, to any 



SYMPTOMS.— STATE OF THE MUSCLES. 51 

considerable extent. The feeling of soreness, occurring in the 
access of the disease, which has already been mentioned, appears 
to have its seat rather in the muscles than in the skin. 

Sec. VIII. — State of the Muscles. Irregular spasmodic con- 
tractions, or permanent rigidity of certain muscles, occur in a mo- 
derate proportion of cases of typhoid fever. The most common 
are those of the fingers and wrist, to which the term suhsultus 
tendinum has been applied. Sometimes they affect the muscles 
of the face, or that of the diaphragm, occasioning hickup. 
Wherever they are seated, they are generally present in the late 
stages, and near the close of the disease. They are much more 
common in grave and fatal cases, than in those of an opposite 
character. Louis found them present, in some form, either that 
of spasms or permanent rigidity, in one-third of his fatal cases ; 
while of fifty-seven cases, somewhat severe, but terminating in 
recovery, there were spasms in only six. Of Dr. Jackson's cases, 
suhsultus tendinum was noticed in 1 of 3.36, which were fatal, 
and in 1 of 10.03, which recovered. Permanent contraction of 
the muscles, generally of those of the arm, is almost invariably 
confined to cases, which are about to end fatally. Dr. Jackson 
and Chomel report each one instance of this kind, which termi- 
nated favorably. Suhsultus tendinum seems to be less frequent 
in children than in adults.^ 

One of the most constant and characteristic phenomena of 
typhoid fever consists in prostration of the muscular strength. 
In very many cases, this is extreme, even in the early periods of 
the disease. A great majority of patients take to their beds at 
the beginning of the disease, and remain there almost constantly 
until the commencement of convalescence. They wall suffer 
themselves to be placed passively in a chair, in order that their 
beds may be made up and aired, but they are impatient and 
anxious to be returned as quickly as possible. When this pros- 
tration is extreme, unless there are great restlessness and distress, 
or delirium, the patient lies continually in the same position, on 
his back, entirely passive, with hardly sufficient strength to move 
his limbs. It is necessary for his attendants to raise him up in 
bed, and to hold to his lips the cup when he drinks. Conversa- 

' Barthez and Rilliet. 



52 TYPHOID FEVER. 

tion, addressed to him, is irksome and fatiguing, and he answers 
questions with reluctance and with a painful effort of his exhausted 
strength. Forget mentions, in very grave adynamic cases, a 
common position of the patient, his arms extended upon the chest 
and abdomen, and the hands resting upon the genital organs. 

I have already remarked, that this feeling of debility is early 
in its appearance. Chomel says, that patients, in reply to the 
question put to them at the first visit, how they came to the 
Hotel Dieu, always answered,— "in a carriage, or supported by 
two friends, for we were not strong enough to come alone on 
foot." In nearly all the fatal and grave cases, it is very strongly 
marked ; in mild cases, it is still present, but in a more moderate 
degree. Occasional exceptions are met with. Louis mentions 
instances, in which the patients kept about for a week, and even 
a fortnight, some of them continuing their accustomed occupa- 
tions. Some of these were fatal cases. I have seen one striking 
instance of this character. The patient did not confine herself to 
the bed, until the occurrence of intestinal perforation. 

This debility, when it is once present, rarely disappears or di- 
minishes, until the close of the disease. A slight increase of mus- 
cular strength, shown by turning for a short time upon the side, 
or by a disposition to sit a little longer than is necessary in the 
chair, is one of the first and most cheering indications of return- 
ing health. 



ARTICLE V. 

DIGESTIVE, AND ABDOMINAL SYMPTOMS. 

I now come to the consideration of a group of morbid phe- 
nomena, not less extensive, various, and important, than those 
connected with the nervous apparatus. I allude to the symptoms 
consisting in disturbances of the entire complex function of diges- 
tion. These symptoms are more characteristic, indeed, of typhoid 
fever, than those which have just been described. We rely upon 
them, as one of our surest means of distinguishing between cases 
of this disease, and those of the analogous form of fever, which 
will next be described, under the name of typhus. For this reason, 
especially, as well as in accordance with the general plan and 



SYMPTOMS.— TONGUE AND MOUTH. 53 

object of this history, I shall treat of them, particularly, and in 
detail. 

Sec. I. — Tongue and Mouth. In a certain proportion of cases, 
the tongue is but slightly altered in its appearance, and this is 
true of the disease in all its grades of severity. Even in fatal 
cases, if they terminate early, that is, during the course of the 
second week, it not unfrequently happens, that the tongue is 
merely covered with a light fur, and is not quite as moist as it is 
in health. When the disease is very mild, the tongue is often 
almost natural in its appearance, or covered only with a light, 
yellowish coat. At other times, under the same circumstances, 
it is smooth, moderately red, and moist with a tenacious, adhesive 
matter. This glutinous exudation is, indeed, very common, in 
all forms of the disease, the severe as well as the moderate. Be- 
sides this, there are other changes, which are found in a majority 
of cases, especially in those which are grave and protracted. 
Sometimes the tongue, having been covered with a light, or yel- 
lowish, moist coating, for a few days, gradually becomes dry and 
brown in a stripe along its middle, and red at its tip and round 
its edges. In other cases, or later in these, it becomes dark over 
its whole surface; sometimes nearly black, glazed, stiff, and 
crossed by cracks and fissures. Sometimes this dark, dry crust 
peels off in flakes or patches, leaving the mucous membrane 
naked, red and shining. This process of coating and denuding 
may be repeated several times in the course of a severe and pro- 
tracted case. In a small number of instances there is a whitish, 
aphthous exudation upon the tongue, and also upon other portions 
of the mucous membrane of the mouth, like that which is often 
seen in the last stages of phthisis pulmonalis, and some other 
chronic diseases. It is generally found where the tongue is mor- 
bidly red, and only at a late period of the fever, when there is 
great debility. In these cases, as well as in others, where there 
is a morbid redness, the tongue is not unfrequently swollen, pain- 
ful and tender. Now and then, it is the seat of ulceration. The 
cracked, brown, and blackish tongue is not so common amongst 
children as it is in adults.^ 

* Barthez and Rilliet. 



54 TYPHOID FEVER. 

The patient often finds a good deal of difficulty in protruding 
the tongue, particularly when it is dry, stiff and fissured, or 
covered with the tenacious secretion. Under these circumstances, 
even if the mind is sufficiently clear, and the will active, the tip 
and sides stick to the lips, and it is only after repeated efforts, that 
it is finally put out. Not unfrequently, it is protruded with a 
tremulous motion. 

The dryness and redness of the mucous membrane often ex- 
tend to the different portions covering the posterior fauces, giving 
rise to more or less difficulty of swallowing, and to other disa- 
greeable or painful sensations. The lips are also often cracked 
and covered with dry crusts, and the teeth, especially near the 
gums, are lined with a dark, tenacious sordes. The secretion of 
saliva is commonly scanty, and its quality changed. 

Sec. II. — Appetite and Thirst. The desire for food is almost 
invariably absent, from the beginning to the end of the disease. 
The very idea of eating is offensive. A return of the appetite is 
amongst the earliest indications of recovery. The thirst is, in 
most cases, proportionate to the degree of febrile excitement. 
Sometimes, especially during the paroxysm of fever, it is urgent. 
Cool drinks are commonly preferred, but not always. 

Sec. III. — JYausea and Vomiting. A majority of patients with 
typhoid fever suffer more or less with gastric symptoms. The 
most frequent of these are nausea, vomiting, and epigastric dis- 
tress. Of twenty-four fatal cases mentioned by Louis, there was 
nausea in thirteen, occurring at various periods of the fever, and 
continuing for an uncertain length of time. Of twenty-three fatal 
cases, vomiting was present in twelve. Nausea not unfrequently 
occurs at or near the commencement of the disease ; but vomiting 
takes place more frequently at a later period, especially when the 
matter ejected is of a greenish color and bitter taste, and when 
there is also present epigastric pain or distress. This combina- 
tion of symptoms was first particularly noticed by Louis, and as 
I shall have occasion to say hereafter, was shown by him to be 
associated with a peculiar lesion of the stomach. Vomiting, at 
or near the commencement of the disease, is more frequent in 
cases of children, than in those of adults. 

Pain or distress in the region of the stomach, varying consider- 



SYMPTOMS.— STATE OF THE BOWELS. 55 

ably in character and severity, is still more common, than either 
nausea or vomiting. Finally, there are many instances, in which 
patients go through the fever without the occurrence of any one 
of these strictly gastric symptoms. In regard to this point, Na- 
than Smith says, — " sometimes, nausea and vomiting take place. 
Sometimes, the matter thrown up consists wholly of vitiated mu- 
cus ; at others, it is mixed with bile of an unhealthy color and 
consistence."^ 

Sec. IV. — State of the Bow els. Amongst the most frequent, and 
when taken in connection with other phenomena, amongst the 
most characteristic symptoms of typhoid fever, is diarrhoea. This 
symptom varies very much in different cases,, in regard to the 
period of its commencement, its degree, its duration, and so on. 
As a general rule, it is most common and severe in long-continued 
and grave cases, and least so in those of an opposite character. 
It was present in all but three of Louis's fatal cases. When the 
disease is mild, it is frequently wholly absent. It varies in severity, 
from one or two discharges to twenty, or more, in the course of 
twenty-four hours. It commences at different periods of the fever. 
Of forty fatal cases, cited by Louis, in which this point was pre- 
cisely ascertained, diarrhoea was present on the first day of the 
disease in tw^enty-two. In others, it begun from the third to the 
fourteenth day.^ In mild cases, it is frequently w^ anting, and 
when present, commonly makes its appearance later in the disease, 
is less urgent, and of shorter continuance. It is commonly a pro- 
tracted symptom in severe cases, its average duration, according 
to Louis, being nearly four weeks. Nathan Smith says, — "the 
latter stage of all severe cases is attended with diarrhoea.*' In 
fatal and grave cases, late in the disease, the discharges are often 
involuntary, and wholly without the consciousness of the patient. 

The stools are, generally, liquid, somewhat turbid, and of a 
yellowish color, in appearance not unlike new cider. In a con- 
siderable number of cases, they are of a dark brown color. Their 
smell is fetid and offensive. Occasionally, they contain portions 
of blood, and sometimes, free and repeated hemorrhage takes 
place from the bowels. According to Dr. Jackson, this discharge 
occurred in the Massachusetts General Hospital in about one-tenth 

* Smith's Medical and Surgical Memoirs, p. 64. 
2 Louis's Researches, vol. i. p. 464, 2d ed. 



56 TYPHOID FEVER. 

of the cases. It takes place most frequently during the second 
week of the disease. It appears, from the researches of M. Taupin, 
to be less frequent in patients under fifteen years, than amongst 
adults. He met with but one instance, in one hundred and 
twenty-one cases ; and Barthez and Rilliet, in one hundred and 
eleven cases, met with none. A more exact estimate of the im- 
portance of this symptom, as well as of others, as a means of 
prognosis, will be made hereafter. Louis says it is exceedingly 
rare to find any mucus in the dejections. 

Dr. Hale, of Boston, thinks that diarrhoea is a more frequent 
symptom in the typhoid fever of Paris, than in that of New Eng- 
land ; and the Report of Dr. Jackson seems to corroborate this 
opinion. This may be so, but I do not think that the data from 
which the opinion is derived are sufficiently accurate and positive 
to settle this matter. It seems very probable, that the records of 
the Massachusetts General Hospital do not always call that con- 
dition of the alvine evacuations, diarrhcea, to which the term is 
applied by Louis. It is true, at any rate, that such is the case 
with the great mass of American practitioners. Certainly, as a 
general rule, they do not, as Louis does, apply the term diarrhoea 
to that state of the bowels, in which only one or two thin dis- 
charges occur in the course of twenty-four hours. In this way 
the apparent difference may, perhaps, be accounted for. 

Professor Schonlein of Zurich, in 1835, found in the intestinal 
discharges a great number of microscopical crystals, perfectly 
transparent, slightly fragile, soluble in muriatic and nitric acids, 
and consisting chiefly of phosphate of lime, some sulphate of 
lime, and a salt of soda. Similar crystals were subsequently 
found, but in much smaller quantity, and much less constant- 
ly, in the intestinal discharges in other diseases.^ 

Diarrhcea, according to Barthez and Rilliet, is invariably pre- 
sent in the typhoid fever of children. 

Sec. V. — Ahdominal Pains. Pain in the abdomen is another 
very common accompaniment of typhoid fever. Its severity and 
frequency are in pretty direct relation to the severity of the dis- 
ease, and to the extent of the diarrhcea. Like the latter symptom, 
the pains in the abdomen are often present at the beginning of 

* EJin. Med, and Surg. Journ., vol. xlviii. p. 253. 



SYMPTOMS.—TYMPANITES. 57 

the fever. At other times, the pain appears at difTerent periods 
of the disease. In some cases, it is only elicited by pressure, but 
more frequently, it is independent of this. It varies in severity, 
from a dull heavy ache, or feeling of distress, to a severe, colicky 
griping. It is not often diffused over the whole abdomen, its most 
common seat being the iliac fossa?, the hypogastrium, and around 
the umbilicus. This symptom, in many cases, constitutes the 
principal source of suffering to the patient, during nearly the 
entire progress of the fever. 

In a certain proportion of cases, generally after the middle 
period of the disease, and sometimes during convalescence, there 
is a sudden supervention of very acute pain in the abdomen, at 
first confined to a small space, but extending pretty rapidly over 
the entire belly. The pain is accompanied by great tenderness 
on motion, or pressure ; tympanitic distention; rapid, feeble, and 
thready pulse; extreme distress; nausea and vomiting; pinched 
and cadaveric features; and these phenomena are speedily fol- 
lowed by death. These are the signs of an acute peritonitis; the 
consequence of intestinal perforation. 

Sec. VI. — Tympanites. Flatulent distention of the abdominal 
parietes is a very common, and to a considerable extent, charac- 
teristic symptom of this disease. Its degree and frequency, like 
the diarrhoea and abdominal pains, wuth which it is often asso- 
ciated, are, for the most part, proportionate to the gravity of the 
disease. It is commonly later in its appearance than the other 
gastro-intestinal symptoms, showing itself, often, during the 
second and third weeks of the fever. Dr. Hale, in his very ex- 
cellent paper, remarks, that this symptom is found most frequently 
near the beginning of the disease.^ This is directly opposed to 
the result of my own observation, and I think to the best autho- 
rities. It varies in degree, from a slight rigidity of the muscles 
and straightness of the parietes, to the extremest distention ; in 
these cases occasioning, as has already been remarked, by its 
mechanical action on the lungs, no inconsiderable degree of dys- 
pnoea. It generally persists, after its first appearance, till the 
fatal termination, or the approach of convalescence ; although it 
is not unusual for it to vary considerably in degree, at different 

' Med. Com. Mass. Med. Soc, 1S39. 



58 . TYPHOID FEVER. 

periods of the fever. The flatus rarely passes off, per anum, and 
seems to be but little disturbed by the peristaltic motion of the 
intestines. 

There is another symptom, connected with the abdomen, which 
may be mentioned here. It was first particularly noticed, so far 
as I know, by Chomel, though it can hardly have escaped the 
attention, I think, of all who have had much to do with the dis- 
ease. I allude to the gurgling sound, which is produced by 
pressure on the abdomen, especially over the region of the coecum. 
If the distention is not excessive, pretty firm pressure, made alter- 
nately with each hand, in the manner of seeking for deeply-seated 
fluid, will rarely fail, I think, to elicit this sensation and sound. 
It is chiefly interesting as one of the elements of our diagnosis. 

ARTICLE VI. 

MISCELLANEOUS SYMPTOMS. 

Under this head I have still to enumerate and describe a cer- 
tain number of morbid phenomena, more or less important, and 
more or less characteristic of typhoid fever, which could not well 
be grouped in any other manner. 

Sec. I. — Emaciation. In most cases of the fever, there is a 
well-marked, and gradually progressive emaciation, although it is 
not often very obvious before the end of the second week. Where 
the disease is severe and prolonged, this emaciation is often ex- 
treme. In cases of great severity, terminating fatally at an early 
period, this symptom is hardly noticed. 

Sec. II. — State of the Urine. Modifications in the urinary se- 
cretion are generally present. Nathan Smith says, — " In the 
commencement of the fever, the urine is not high colored, and is 
considerably copious, being often above the natural quantity, and 
deposits no sediment. In voiding it into a vessel, it often foams 
like new beer. As the disease advances, the urine becomes more 
highly colored, and as it begins to decline, lets fall an abundant 
sediment. In very severe cases, the patient evacuates his bladder 
but seldom, allowing the urine to accumulate there in very large 



SYMPTOMS.— EPISTAXIS.— CUTANEOUS ERUPTIONS. 59 

quantities."^ Drs. Dobler and Skoda, in a description of the 
typhoid fever of Vienna, inform us, that whenever the disease is 
at all severe, the urine deposits no sediment, unless it be a slight 
cloud of mucus. On the subsidence of the fever, there is often a 
grayish, dirty deposition. 

Sec. III. — Epistaxis. Hemorrhage from the mucous mem- 
brane of the nostrils is quite common in the course of typhoid 
fever. Louis ascertained its occurrence in twenty-seven of thirty- 
four patients, who had the fever in a grave form, but recovered. 
It was present in somewhat less than half of his mild cases. It 
may occur at different stages of the disease, but it is most common 
during the early period, or in the first half of its duration. It 
sometimes occurs but once, but is, in many instances, several 
times repeated. It is generally small in quantity, sometimes 
amounting to only a few drops. At other times it is profuse, re- 
quiring the use of the tampon to arrest it. It is rarely, if ever, 
attended with or followed by any relief. It seems to be much less 
common amongst children, than amongst adults.^ 

Sec. IV. — Cutaneous Eruptions, The most frequent and cha- 
racteristic eruption upon the skin consists in w^hat has been called 
the lenticular, rose-colored spot. This, indeed, is so common in 
typhoid fever, and so rarely seen in any other disease, that it has 
received the name of typhoid eruption. It consists of a small spot, 
not a pimple, slightly elevated above the surrounding skin, not 
always sensible to the touch, but generally so, about as large, in 
circumference, on an average, as the head of a pin, and of a 
bright red, or rose color. When the skin is made tense, or pressed 
by the finger, the spot readily disappears^ returning, immediately, 
on the removal of the pressure. 

There is good reason to think, that this eruption is almost an 
invariable accompaniment of typhoid fever. It is true, that 
amongst thirty-six fatal cases, where the eruption was sought for, 
Louis found it in only twenty-six. So, in the Massachusetts 
General Hospital, Dr. Jackson found, during the years 1833, 
1834 and 1835, the rose spots in only two-thirds of the patients. 
But it is very probable, that in many of these cases, the eruption 

' Smith's Medical and Surgical Memoirs, p. 64. 
2 Louis's Researches, vol. ii. p. 84, 2d ed. 



60 TYPHOID FEVER. 

was either overlooked, or that it had disappeared before the patients 
came under the care of their respective physicians. All the grave 
cases, which recovered, cited by Louis, excepting three ; and all 
his mild cases, without any exception, exhibited this eruption. 
Dr. Hale found the rose spots in one hundred and seventy-seven 
of one hundred and ninety-seven cases, and in a greater part of 
the remaining twenty, they were not carefully sought for.^ 

Louis says, in his second edition, that of fifty-four cases, care- 
fully and daily observed, at La Pitie and the Hotel Dieu, subse- 
quent to the publication of his Researches, the rose eruption was 
present in all but five. In these it was wholly wanting. I have 
rarely failed to find it where it was properly sought for. 

It appears from the observations of Rilliet and Taupin,that this 
sign is as common in early as it is in adult life. It frequently 
appears a day or two sooner in cases of children. Taupin says, 
that he has never seen this eruption, in the course of any other 
disease amongst children, and he mentions, particularly, menin- 
gitis; of which he has witnessed more than two hundred cases. ^ 

It is found on various parts of the body, but much more fre- 
quently than elsewhere upon the abdomen and the chest. Now 
and then, it is seen upon the skin of the extremities and of the 
face. It is also found upon the back. 

The spots vary in number. Sometimes, they are but few, — 
six, eight, or ten. In other cases, they are much more numerous, 
being sprinkled pretty abundantly over the chest and abdomen. 

Dr. Jackson, of Boston, informs me, that he has seen them 
quite thickly scattered over the entire surface, even that of the 
limbs. I have this day, August 6th, 1842, visited a patient, sick 
about a fortnight with typhoid fever, who exhibits the spots upon 
every part of the skin, excepting that of the hands, ankles and 
feet. There are not less than twenty upon the face, and as many 
as forty may be counted on the left arm between the elbow and 
wrist. Their size varies from that of a small point to a diameter 
of two lines. Most of them are pretty regular in their oval or cir- 
cular outline, although a few of the larger ones are less so. They 
are, many of them at least, slightly but very distinctly elevated 
above the surrounding skin, and can be readily detected by the 
finger. 

' Com. Mass. Med. Soc, 1839. 

=* Louis's Researches, vol. i. p. 106, 2d ed. 



SYMPTOMS.— CUTANEOUS ERUPTIONS.— ESCHARS. 61 

The most usual period of their appearance is during the second 
week of the fever. In a few rare instances, they are seen as early 
as the close of the first week. Of twenty-five cases, in which this 
point was carefully noticed by Chomel, the eruption appeared 
between the sixth and the eighth day of the disease, in two ; be- 
tween the eighth and the fifteenth day, in thirteen ; between the 
fifteenth and the twentieth day, in seven; between the twentieth 
and the thirtieth day, in four; and on the thirty-seventh day, in 
one.^ They generally come out successively, one after another, 
and after remaining, commonly, for little more than a week, they 
successively and gradually fade away and disappear. 

Another pretty common eruption consists in transparent vesi- 
cles, to which the name sudamina has been given. These vesi- 
cles are circular, or oval in their shape, varying in size from that 
of a small pin's head, to that of a split pea. They are formed 
by the presence of a limpid fluid elevating the cuticle. Their 
most frequent seat is upon the sides of the neck, and about the 
shoulders and axilla^, though they are sometimes scattered more 
extensively over the body. Chomel says that he has never seen 
them on the face. They are most readily seen, when looked at 
in an (3blique direction. They appear late in the disease, being 
rarely seen before the twelfth day. They usually remain for 
several days, and gradually disappear. They were present in 
two-thirds of Louis's cases, where they were carefully sought for, 
and in the same proportion, whatever was the severity of the 
fever. Dr. Hale attaches much less importance to sudamina as 
a diagnostic sign of typhoid fever than Louis and Chomel. He 
says, — " wherever the skin is for a length of time kept in a state 
of perspiration, from whatever cause, there sudamina will gene- 
rally be found." This is far from being in accordance with the 
observations of Louis and Chomel. Louis says, that of forty 
patients with other diseases, in all of whom there w^ere copious 
sweats, only three exhibited sudamina. 

Sec. V. — Eschars. In this place may be properly noticed the 
tendency which exists, particularly in grave and protracted cases 
of typhoid fever, to ulceration of the skin. This is occasionally 
shown in the formation of ulcers upon the sacrum. In similar 

* Chomel, p. 20. 



62 TYPHOID FEVER. 

cases, it not unfrequently happens, that blistered surfaces are 
attacked with ulceration. They become, especially about the 
edges, covered with a white or grayish exudation, like that which 
is frequently seen on blistered surfaces, in cases of protracted 
scarlatina, and which is commonly called canker. The ulceration 
underneath this matter, sometimes becomes deep and extensive, 
adding, in no small degree, to the irritation of the disease. In 
some cases, true gangrene occurs, followed by eschars and slough- 
ing. 

In a moderate proportion of grave cases, typhoid fever is com- 
plicated with erysipelatous inflammation of the skin. I have 
known this erysipelatous tendency show itself in a disposition to 
attack the end of the nose. Biles appear, occasionally, upon dif- 
ferent parts of the body, on the approach, or after the commence- 
ment of convalescence. 

I have now completed the enumeration and description of the 
symptoms of typhoid fever. Some of these symptoms are more 
important, more frequently present, and more characteristic of the 
disease, than others. Some, again, are chiefly interesting and 
valuable as diagnostic, and others as prognostic, indications. It 
very rarely happens, that in any single case, they are all united. 
Under different circumstances, and in different cases, they are 
very variously combined, constituting different grades and varie- 
ties of the disease. These varieties might, properly enough, be 
described in this place ; but I think it better to defer this descrip- 
tion, until after the anatomical lesions of the disease, and the re- 
lations, so far as these have been ascertained, between the symp- 
toms and the lesions, have been given. I shall thus be enabled 
to present to the reader a more distinct, individualized and un- 
broken picture of the disease, with its ordinary and average fea- 
tures, than can otherwise be done. The varieties in its march, in 
its severity, in the grouping and combination of its numerous 
symptoms, will then be considered, in their place, amongst the 
other complex elements in the natural history of the disease. 



63 



CHAPTER III. 

ANATOMICAL LESIONS. 

Chomel, in his very excellent and full description of th*e patho- 
logical alterations in typhoid fever, divides them into two classes, 
consisting, respectively, of those which are constant and charaC' 
teristic, and of those which are occasional. Louis does not attempt 
to follow any natural or systematic arrangement. In the present 
history, as a matter of convenience, I shall pursue, as far as this 
can well be done, the same general order in the succession of 
subjects, that I adopted in the detail of symptoms; pointing out, 
under each head, the connections between the symptoms of the 
disease, and the lesions of the organs, so far as this connection 
has been ascertained. 

ARTICLE I. 

LESIONS OF THE CIRCULATORY APPARATUS. 

Sec. I. — Heai't and Aorta. The most striking and common 
alteration of the heart consists in a diminution of its consistence. 
Louis found this organ natural, in volume, color, and consistence, 
in one-half of his cases. In seventeen of forty-six cases, the soft- 
ening was very well marked. Its tissue could be very readily 
torn and broken down. At the same time, the heart is exceed- 
ingly flaccid, assuming, when removed from the body, a collapsed 
and flattened shape. The softening of the texture, and the gene- 
ral flaccidity, are most commonly found together, though they 
may exist separately. Under these circumstances, the cut sur- 
faces of the heart have a dull, dry appearance, and the w^alls of 
the ventricles are, in most cases, diminished in thickness.^ These 
changes in the condition of the heart are usually accompanied 

' Louis's Researches on Typhoid Fever, vol. i, p. 331. 



64 TYPHOID FEVER. 

with alterations in its color. The muscular tissue and the exter- 
nal surface are pale, in many cases, with a violet or livid tinge. 
The internal surface is sometimes pale, and sometimes of a more 
or less deep, violet red. These alterations are found more fre- 
quently and more strongly marked, in cases which have termi- 
nated early, than in those which have been prolonged. It would 
seem, that at the Massachusetts General Hospital, lesions of the 
heart are of less frequent occurrence. Of twenty-eight cases no- 
ticed in Dr. Hale's Remarks, only two or three are said to have 
been *' rather flaccid." It ought, however, to be remembered, 
that this term might be applied to the same condition of the heart 
by one observer, and withheld by another. There have been dif- 
ferences of opinion, amongst pathologists, in regard to the nature 
of these lesions. I do not think there is any satisfactory evidence 
that they are inflammatory. 

The aorta is frequently more or less changed in color, on its 
internal surface. This change existed in somewhat more than 
one-half of Louis's cases. It consists of a morbid redness, more 
or less intense, sometimes in the form of bands or patches, some- 
times generally diflused over the whole surface, and extending to 
the bifurcation of the aorta, or even considerably beyond it. This 
redness reaches through the inner, and affects, though in a less 
degree, the middle membrane of the cardiac cavities. The intens- 
ity of the morbid color is generally in proportion to the softening 
and flaccidity of the tissue of the heart. It is always found in 
connection with the presence of blood in the aorta; and it is im- 
portant to remark, further, that the most extreme cases of soften- 
ing of the heart commonly co-exist with the presence of a dark, 
soft, non-fibrinous clot of blood in its cavities, or with blood not 
coagulated, but containing bubbles of air.^ 

The cause and nature of this reddening of the inner coats of 
the aorta have been the subjects of much investigation and much 
controversy. There is no place for any account of them here. I 
will merely say, that the opinion of Louis seems to me most in 
accordance with all the phenomena, which enter into the solution 
of the question; and that opinion is, that this redness is the result 
of imbibition, by the tissues, of the coloring matter of the blood,— 
the imbibition depending upon a special condition of the blood, 

* Louis's Researches on Typhoid Fever, vol, i. p. 333. 



LESIONS.— STATE OF THE BLOOD. 



65 



or of the tissues, or, perhaps, of both. There is no conchisive 
evidence, at any rate, that the redness is the result of inllamma- 
tion. 



Sec. II. — State of the Blood. The most frequent alteration in 
the character of the blood consists in the diminution of the natural 
proportion of its fibrine. In some cases, the cavities of the heart, 
especially the right, contain fibrinous concretions of a whitish or 
yellowish color; but more commonly, the blood is in the form of 
dark coagula, or entirely fluid. Of thirty cases, wherein the blood, 
contained in the heart and aorta, was carefully examined by 
Chomel, he found small and scanty fibrinous concretions in six, 
dark coagula in nine, and dark, fluid blood in fifteen. The occa- 
sional presence of air in this uncoagulated blood has already been 
noticed. According to the observations of Louis, the appearance 
of the blood, contained in the cavities of the heart, as has just 
been intimated, varies with the condition of this organ. When its 
consistence was natural, he found, especially in the right cavities, 
yellowish or whitish fibrinous coagula, more or less firm; when it 
was considerably softened, he found non-fibrinous coagula; and 
when the softening was very great, instead of coagula, he found 
only a small quantity of fluid blood containing air. 

Blood drawn from the veins, during life, rarely exhibits the 
buflfy coat; and when this is present, it is generally soft, gela- 
tinous, or infiltrated, and of a grayish or greenish color. This 
character of the blood has been particularly noticed by Louis, 
Chomel, and Bouillaud ; and the results of their observations have 
been abundantly verified by the subsequent and more accurate 
researches of Andral and Gavarret. They found that, in typhoid 
fever, the proportion of fibrine in the blood was never increased 
above its natural standard; but, on the contrary, that in many 
cases this proportion was very much diminished; and, further- 
more, that the degree of this diminution was very uniformly pro- 
portionate to the severity of the disease. These observers found 
a similar alteration of the blood in the eruptive fevers, while in 
all cases of simple acute inflammation, the quantity of fibrine was 
above its natural standard. 
5 



gg TYPHOID FEVER. 

ARTICLE II. 

LESIONS OF THE RESPIRATORY APPARATUS. 

Sec. L— Lungs. Neither the symptoms nor the lesions go to 
show, that the lungs play any very important part in the nume- 
rous and complicated phenomena of typhoid fever. Louis found 
them nearly natural in fifteen of forty-six cases ; about the same 
proportion in which he found them so in other acute diseases, 
excluding, of course, those of the lungs themselves. Chomel 
found them healthy in ten of forty-two cases. The most charac- 
teristic alteration is described particularly by Louis, and, so far as 
I am aware, has not been noticed by other writers. It is of fre- 
quent occurrence in the fever of our own country. It has been 
called splenization, or carnification of the lung. The latter term 
may be well enough, but the former is wholly inappropriate ; the 
appearance of the lung being entirely unlike that of the spleen. 
The portion of lung thus carnified, is of a deep, bluish red color ; 
it has a tough, leathery feel; the finger penetrates and breaks it 
down with difficulty ; it is wholly destitute of air, and sinks readily 
in water. When it is cut, the smooth surface is directly covered 
with a thick, red fluid. This peculiar lesion almost always oc- 
cupies a circumscribed portion of the lower and posterior lobe of 
one or both lungs. It is quite unlike, in almost every respect, 
the second stage of inflammation, although the term hepatization 
has sometimes been applied to it. It is not indicated by any 
peculiar symptom during life. 

Other changes, such as inflammation, usually not extensive ; 
simple mechanical engorgement, taking place during the last hours 
of life ; violet red spots or patches in the infero-posterior portions 
of the lung ; circumscribed abscesses ^nd tubercles, are present 
in a certain proportion of cases. The inflammation is often not 
discoverable during life, except by its physical signs. 

Sec. II. — Bronchia, Epiglottis, ^c. The mucous membrane of 
the bronchial tubes is frequently of a more or less livid red color, 
sometimes with a violet tinge. That of the trachea is occasion- 
ally colored in the same manner, but is very rarely the seat of 
any unequivocal lesion. The same thing is true of the larynx. 
The epiglottis is more frequently and seriously diseased. In a 



LESIONS.— BRAIN AND ITS MEMBRANES. 67 

moderate proportion of cases, it is the seat of ulcerations, extend- 
ing not only through its investing membrane, but into the fibro- 
cartilage itself; occasioning, sometimes, extensive destruction of 
the organ. In other cases, it is simply denuded. These ulcera- 
tions are not found where the disease is rapidly fatal. They are 
frequently productive of some difficulty of swallowing. 

Recent lesions of the pleura are very rare. In many cases, 
there is an effiision of bloody serum, varying in quantity, from a 
few ounces to a pint or more, occupying both sides of the chest. 
This exudation probably takes place near the close of life. 

ARTICLE III. 

LESIONS OF THE BRAIN AND ITS MEMBRANES. 

From the frequency and severity of the symptoms, consisting 
in deranged action of the brain, it w^ould have been supposed, as 
a mere matter of a priori reasoning, that this organ w^ould have 
exhibited corresponding alterations in its appearance. Such, 
however, is far from being the fact. As will be seen by the 
details w^hich I am about to give, lesions of the brain are far from 
being universally present, and, w^hen present, far from being 
found in any constant relation to the disturbed functions of the 
organ during life. Of thirty-eight cases, reported by Chomel, in 
which the brain and its membranes were carefully examined, 
fifteen presented no appreciable alterations in these organs.^ The 
most common changes, in a certain proportion of cases, consist of 
moderate serous effusion between the arachnoid and pia mater; 
more or less vascularity of the pia mater itself; a rosy tinge of the 
cortical substance, and injection of the medullary portion of the 
brain. Of forty-six cases, Louis found the sub-arachnoid effusion, 
various in degree, in twenty-eight; vascularity of the pia mater in 
somew^hat less than one-half; the rosy tinge of the cortical sub- 
stance, uniformly diffused through its entire extent, in seventeen, 
and more or less injection of the medullary substance in all but 
eight. This injection is generally proportionate to the red color 
of the gray substance, and both phenomena are most common 
and strongly marked in cases which terminate early. The serous 
effusions, on the other hand, are more frequently found in cases 

'■ Chorael's Lemons de Clinique Medicale, p. 294. 



gg TYPHOID WRTKSi. 

that haTe been protracted. In rare instances, there is a sli^t 
increase or diminution in the consistence of the brain, besides 
some other nnimportant and accidental alterations. 

In regard to the nature of these several lesions, there is, amongst 
pathologists, a diflference of opinion. Those who still cling to 
the doctrines of the old and exclosiTe physiol<^cal school, and 
who are hannted by the perpetual presence of irrUaUony r^aid 
the foregoing changes as the evidence and result of inflammatory 
action. Others think, that not only is there no satisfactory proof 
of the action of this morbid element, but that there are many and 
insuperable objections to such an opinion. 

There is no ascertained relation between the cerebral symptoms, 
during life, and the pathological conditions of the brain and its 
membranes, appreciable a&er de:.h. P and somnolence 

are found to have occurred as ::t: r:r. ': b^ve been as 

strongly marked, in patients wV ^ , : ; r no changes, 

or exceedingly slight ones, :: T : . si. . t pposite 

character. Again, it is ot: t^ : is It :: r/: ^sj 

peculiar to typhoid fever, s::. ; : t : l: : s: : 5 :: r : intly 

in patients dead from other acu: t : s 7 \ z :: : i :. _ :: : s e of the 
brain itself and its envelops, as ih. ilisz c^rac. iicLi :he lever. 



ARTICLE IV. 

LESIOIfS OF THE DIGESTTTE JLSD ABDOMESfAL OBGA^fS. 

Sec. I. — PJmrynx a->-.d CErz\agiis. In a larr^ r ::-; rrirr. ^f 
cases of typhoid fever. -St rrgans are found ::- li: ;. 1 :_:^^ 
state. The only lesici. :::y considerable frequency, which 
they exhibit, consists iii ulcerations of their mucous linicc. 
These were noticed by Louis, in the pharynx, in eig^t of forr - 
ax cases; and in the oesophagus, in nearly the same proporti::. 
They vary in size, from one to six or eight lines in diameter, a: 
circular, or oval in shape, and generally quite superficial. Ii. 
many of these cases, there is difficult or painful deglutition. In 
others, especially where there is delirium, this symptom is whoDy 
wanting, as it sometimes is, under the same circumstances, in 
cases of ulceration and partial destruction of the epiglottis. 

Sec. II. — Stonuuh. The mucous membrane of the stomach. 



LESIONS.— STOMACH. 69 

unlike that of the pharynx and esophagus, is generally more or 
less removed from a healthy condition. Louis found it free from 
any obvious lesion, excepting an occasional slight change of color, 
in about one-third only of his cases. The alterations of which it 
is the seat are various. The most common consist of changes in 
its color, its consistence, its thickness, in mamellonation, and 
ulceration. These alterations may exist separately, or, as hap- 
pens more frequently, two or more of them are found together. 
The most common change of color consists of increased degrees 
of redness. This redness is of various shades, occupies different 
portions of the stomach, most commonly the great tuberosity, and 
seems to be dependent on different causes. Sometimes, even 
when not connected wdth any other change in the membrane, it 
is, probably, the result of inflammatory action ; but in many 
instances, there is sufficient evidence, that such is not the case. 

Softening of the mucous membrane, sometimes existing as a 
simple lesion, is frequently associated w^ith a diminution of its 
natural thickness. This alteration, either simple or complicated, 
is found in all parts of^the membrane, but it is oftenest confined 
to that of the cardiac extremity. Of fourteen cases, mentioned 
by Chomel, the softening was limited to this region, in ten. In 
some cases, it exists in separate bands ; in others, it spreads over 
a continuous portion of the stomach. The thinning occasionally 
extends through the membrane, resulting, of coarse, in its entire 
destruction. The softening with thinning is found, nearly always, 
in those cases, which terminate before the twenty-fifth day of the 
fever. ^ 

Ulcerations of the mucous membrane are present in a few^ in- 
stances. Louis found them in four of forty-six cases. Of forty- 
two cases quoted by Chomel, they were not found in any. These 
ulcerations are small in size, superficial, and not very numerous. 
There is another pathological state of the gastric mucous surface, 
to which the name mamellonation has been applied. This lesion 
consists of small elevations of the membrane, pretty regularly 
circular, or oval in their form, and scattered thickly, and in con- 
siderable numbers over different portions of the stomach. This 
peculiar condition generally exists, in connection with other alter- 
ations, especially with softening, and increased redness. Like 

* Louis's Researches on Typhoid Fever, vol. i, p. 173, 1st ed. 



70 TYPHOID FEVER. 

most of the gastric lesions, it is oftener present in cases which 
terminate early, than in those which are prolonged. 

Louis has taken great pains to ascertain the relationship, if any 
such exists, between these various pathological states of the gas- 
tric mucous membrane, and the gastric symptoms. The result 
of his inquiries is this : — that in a considerable number of cases, 
the several lesions, separately or combined, are found after death, 
when there had been no gastric indications of their presence 
during life ; and that epigastric distress, either alone, or with 
nausea, not unfrequentlyhas occurred in cases where the mucous 
membrane of the stomach was found in a healthy condition. All 
the cases, however, in which there was epigastric distress, ac- 
companied by repeated vomiting of bile, exhibited more or less 
extensive disease of the membrane.^ So far as the absence of 
any constant relationship between the lesions of the stomach and 
the gastric symptoms is concerned, the conclusions of Louis are 
abundantly sustained by the researches of Chomel.^ 

Sec. in. — iS'??ia// Intestines. In all cases of typhoid fever, there 
is lesion of the small intestines. This lesion is peculiar. It is 
found in no other disease. It is generally extensive. Constitut- 
ing, as this lesion does, the characteristic, and, of course, the 
most interesting and important pathological element of typhoid 
fever, I shall describe it with all possible accuracy and complete- 
ness. Before proceeding, however, to do this, I will more briefly 
enumerate certain other occasional changes that are found in the 
small intestines. 

The duodenum is not often the seat of any ver}' considerable 
disease. Not unfrequently, it is entirely natural; at other times, 
the mucous membrane is morbidly red, softened, and, very rarely, 
the seat of a small number of minute, superficial ulcerations. 

The small intestines are moderately distended with flatus, in a 
few cases. Their contents consist, commonly, of a considerable 
quantity of mucus, especially in the upper portion, and of liquid, 
bilious matter, of a light yellow or orange color, sometimes tinged 
w^ith red. In cases where there has been hemorrhage from the 
bowels, blood, either coagulated, or dark colored, and grumous, 
is found in the intestines. 

* Louis's Researches on Tjrphoid Fever, vol. i. p. 457, et seq., 2d ed, 
' Legons de Clinique Medicale. Par A. F. Chomel, p. 247, et seq. 



LESIONS.— SMALL INTESTINES. "^1 

In many of these same cases, and in some others where there 
has been no hemorrhage, and where no blood is found in the in- 
testines, the mucous membrane is the seat of sanguineous infiltra- 
tion. This condition has been particularly described by Chomel. 
I have seen it more extensive, and more strongly marked in two 
cases of death from acute jaundice, in both of which there were 
hemorrhagic discharges from the bowels, than in typhoid fever. 
It may exist to the extent of only a few inches, or of severel feet. 
It is generally continuous, not in patches or zones. The color of 
the membrane ranges from a rose to a very dark red, and it has 
a peculiarly brilliant and trembling or quivering appearance, like 
jelly. Chomel found this lesion in seven of forty-two cases. He 
is very confident, that it is intimately connected with hemorrhage 
from that portion of the membrane, which it occupies.^ 

The mucous membrane, exclusive of the elliptical plates and 
the isolated follicles, is, in a majority of cases, more or less changed 
in color. In many, it is preternaturally red. This redness is 
sometimes continuous, and extends through a large portion of the 
intestinal tract; at other times, and more frequently, it exists in 
patches or zones. Occasionally the color is grayish; this is par- 
ticularly the case w^hen the disease has been protracted to a late 
period. 

The consistence of the membrane, like its color, is found, in a 
moderate proportion of cases, quite natural. . Oftener, however, it 
is more or less diminished ; sometimes so much so as to resemble 
an unorganized pulp, spread, like a layer of paste, over the sub- 
jacent tissue. This softening is in some cases quite simple ; that 
is, it is not connected with any other appreciable alteration. In 
others, the membrane is, at the same time, reddened or thickened, 
or both. It is the opinion of Louis, that these two forms of soft- 
ening are unlike in their character and causes. The latter he 
considers to be inflammatory; the former he thinks may depend 
on different causes, but that it is not the result of inflammation. 
In a part, at least, of the cases, he is inclined to regard it as the 
result of a post-mortem or cadaveric change. 

The invariable and characteristic lesion found in the small in- 
testines, to which allusion has been made, consists in alterations, 
differing somewhat in different cases, of the elliptical plates, or 

' Le9ons de Clinique Medicale. Par A. F. Chomel, p. 252, et seq. 



72 TYPHOID FEVER. 

Peyer^s glands. The condition in ^hich these bodies are found 
varies ^ith the duration of the disease, ^vith the distance of the 
plates themselves from the ileo-cecal ralve, and v\-ith other cir- 
cumstances, the nature of which is unknown. ^Yithout entering 
into so minute and elaborate a description of the several forms of 
this lesion as has been, veiy properly, given, in the original re- 
searches of Louis, and Chomel, I shall enumerate the principal and 
more striking varieties. 

In a small proportion of cases, consisting of those which termi- 
nate early, the elliptical plates, together with the subjacent cel- 
lular tissue, are merely increased in thickness, with redness, and 
softenino-. This increase of thickness is such, that the edges of 
the plates project to a distance of from one to two or three lines 
above the surrounding mucous membrane. Sometimes, the hy- 
pertrophy of the plates and of the subjacent tissue is quite simple, 
the color and consistence of the membrane remaining unaltered. 
This simplest form of the lesion, that I am now describing, like 
all the others, which are more complex, is invariably found most 
advanced, and most strongly marked, at the lower extremity of 
the ileum. Each successive plate, as we go upward along the 
intestinal tract, from the ileo-cecal valve, is less and less pro- 
foundly altered, till we arrive at those, which are in a natural 
condition. The number of plates, thus changed, is very various; 
sometimes extending to fifteen or twenty, and at others, limited 
to one or two, and these always in the immediate neighborhood 
of the ileo-cecal valve. Louis says, that in two-thirds of the 
cases, the number of plates, more or less altered, is from twelve 
to forty. 

The surfaces of the thickened plates frequently present a granu- 
lar or finely mamellonated appearance, occasioned by an enlarge- 
ment of the gray orifices of the cryptae, which go to make up the 
plates. This condition becomes very manifest when the gland is 
detached from its subjacent tissue, and held between the eye and 
the light. At other times, the surface of the thickened membrane, 
corresponding to the plates, is quite smooth and level. 

In a great majority of cases, the plates, instead of being merely 
thickened, with or without redness and softening, are more or less 
extensively the seat of ulcerations. These ulcerations vary very 
much in size and in number. It frequently happens, for instance, 
that in proceeding from above downwards, in our examination, 



LESIONS.— SMALL INTESTINES. 73 

after having passed over several plates, simply thickened, we 
come to one of them in which there is a single, circumscribed 
ulceration, with perpendicular edges, extending more or less 
deeply into the thickened tissues. As we go on towards the ter- 
mination of the intestine, the ulcerations become more and more 
numerous, and extensive, till at last, for several inches next to 
the valve, the plates are entirely destroyed, and we find only 
ulcerations, corresponding to their sizes and shapes, occupying 
their places. 

These intestinal ulcerations are commonly more or less regu- 
larly rounded or oval in their shape. Sometimes, however, their 
borders are irregularly jagged, and angular. So, their edges are, 
in most cases, pretty regularly perpendicular and smooth, but 
sometimes they are ragged and shreddy. The bottoms of the ul- 
cerations vary, of course, with their depths. They consist, some- 
times, of the cellular tissue immediately under the mucous mem- 
brane ; sometimes, of the muscular coat, and, sometimes, of the 
peritoneal covering. Occasionally, this covering itself gives way, 
perforation takes place, and the contents of the intestine are dis- 
charged into the cavity of the peritoneum. Louis found this 
lesion, in eight of fifty-five cases. Chomel quotes two instances 
of its occurrence, in his clinique at the Hotel Dieu; in one of 
which, however, the perforation took place in the large intestine. 
The perforation is usually single, small in diameter, and near to 
the termination of the ileum. In one of three cases, mentioned 
by Dr. Hale, it was at the distance of forty-four inches from the 
ileo-cecal valve. It generally takes place at a late period of the 
disease. It is a very singular fact, that this fatal accident com- 
monly occurs in the course of very mild, or almost entirely latent, 
forms of the fever. This was the case in ten of twelve instances 
cited by Chomel. Chomel, suggests that the distention of the in- 
testines by gas, may frequently be the immediate cause of perfo- 
ration. This seems hardly probable, since the greatest distention 
is usually confined to the large intestine, while perforation is most 
frequent in the small. It has occurred to me that the frequency 
of the accident in the mildest, and in some degree, latent form of 
the disease, might possibly be occasioned by mechanical causes, 
especially by efforts of the patient while standing and walking. 

This accident is much less common in children, than in adults. 
Taupin met with it only twice, in one hundred and twenty-one 



74 TYPHOID FEVER. 

cases ; and Barthez and Rilliet only once, in one hundred and 
eleven cases. 

There is another peculiar appearance of the diseased plates, 
which is found in a certain proportion of cases; according to 
Louis, in somewhat less than one-third. This seems to consist 
in a morbid chano-e or transformation of the sub-mucous cellular 
tissue. Instead of being simply hypertrophic, with or without 
redness and softening, as in the cases already described, this tis- 
sue is converted into a substance of a yellowish color, destitute of 
any traces of organization, presenting a surface somewhat glossy 
when cut, and about as hard and friable as crude tubercle. This 
peculiar condition was observed in several subjects, during the 
grave epidemic of 1833-4, in the city of Lowell; and in accord- 
ance with the fact, previously noticed by Louis, it was most fre- 
quent and striking in cases which terminated quite early. This 
would seem to indicate, that the alteration in question is connected 
with the more severe and rapid forms of the disease.^ 

^ M. Forget describes the lesion of Peyer's glands under six diiferent forms. The 
first of these he calls the form poiiitillee, — the punctated or pointed form. It was 
first described by Roederer and Wagler: and its appearance compared with that of 
the beard newly shaven. This condition of the glands has been noticed by Andral, 
Chomel, Forget, and others; but there is no satisfactory evidence that it is espe- 
cially connected with typhoid fever. It is doubted even M^hether the appearance 
is really pathological. It is not often met with. 

The second form is the reticulated. The glands are rarely thickened ; their color 
varies from that of a grayish red to a deep red, and their consistence is greatly di- 
minished. The substance of the glands presents the appearance of a pretty regu- 
lar net-work, resembling somewhat the pulp of a cherry. This appearance is more 
striking when the glands are examined under water. It has been suggested that 
this form may be constituted by the first, or at least by the earlier, changes which 
take place in the glands. 

The third is the honey comb form. It is the hard form of Louis, and has been 
already described. 

The fourth form is the pustular. The peculiarity of this form consists simply in 
the size and shape of the altered glands. These are small and circular, thus occa- 
sioning the pustular appearance. Cruveilhier and Forget think that this pusmlar 
form is generally connected with very grave and rapidly fatal cases of the disease. 

The next form is the gangrenous. Forget says it is always the result of the hard 
or honey comb form. The substance of the gland loses its vitality ; it becomes of a 
yellowish or greenish color ; its edges growing ragged and shreddy are detached ; 
and finally the entii-e gland is thrown ofl", leaving the subjacent muscular or serous 
tissue exposed. 

The sixth is the ulcerated form. This has been already described with a sufficient 
degree of minuteness. 

These lesions of the folhcles, bodi isolated and agminated, can very generally be 



LESIONS.— SMALL INTESTINES.— PEYER'S GLANDS. 75 

I have spoken of this lesion of the glands of Peyer, in some of 
the forms which have now been enumerated, as invariably present 
in typhoid fever. I have also spoken of it, as characteristic of 
this disease. The question of the absoluteness of this pathologi- 
cal law, — of the constancy of the relationship between the intes- 
tinal lesion and the group of symptoms by which we recognize the 
disease, during life, — will be further considered, when I come to 
treat of the diagnosis of typhoid fever. 

The only remaining alterations found in the small intestine, of 
which it is necessary to speak, are those of the isolated follicles, 
or Brunner's glands. Louis found them more or less diseased, in 
twelve of forty-six cases. They are subject to the same changes, 
which have just been described, in connection with the elliptical 
plates, and like the latter, they are most numerously and most 
profoundly altered, in proportion to their proximity to the ileo-cecal 
valve. 

In this disease, as in most others, it sometimes happens, that 
death takes place, unexpectedly, from unknown causes, or from 
indiscretions in diet and regimen, after the establishment of con- 
valescence. These occurrences have enabled us to ascertain the 
appearances of the diseased glands, during their march towards 
their original, healthy condition. The deep red tint, characteris- 
tic of acute inflammation, is found, in these cases, to have given 
place to various shades of gray, ash color, brown, and blue. The 
edges of the ulcerations, if such have existed, are smooth and 
flattened, passing off' imperceptibly, each way, into the bottoms of 
the ulcers, and into the adjacent healthy membrane. These cica- 
trizing ulcers are always confined to the lower portion of the in- 
testine. Of forty-two cases, Chomel found eleven, in which there 
was either partial or complete cicatrization of the ulcerated 
glands ; and in all these, the cicatrization w^as limited to the last 
six or eight inches of the ileum. It would seem to be very cer- 
tain, that the process of restoration in the diseased glands follows 
the same march, from the ileo-cecal valve upwards, which is so 
evidently followed, in the development of the lesions themselves. 

recognized through the outer or peritoneal coat of the intestine. This coat, at the 
points corresponding to the thickened and ulcerated glands, is frequently of a red- 
dish or bluish color, sometimes injected, or even covered with a layer of fibrine; 
and the thickened glands can, in most cases, be distinctly felt by the thumb and 
finger, as chancres, says Forget, can be felt through the prepuce. 



76 TYPHOID FEVER. 

It is the opinion of Ciiomel that, where the cicatrizatioD of the 
ulcers is complete, all traces of the lesion finally disappear. He 
says, that in the numerous autopsies at the Hotel Dieu, in many 
of which there was good reason to think, that the subjects had 
formerly had typhoid fever, there were never found any obvious 
proofe of old ulcerations, in the form of remaining cicatrices. It 
is reasonable to suppose, that in many cases, especially in mild 
forms of the disease, the local lesion terminates in resolution, 
there having been no loss of substance, either by ulceration, or 
gansnrene. 

Sec. IV. — Large Intestine. There are only two alterations of 
the large intestine, especially connected with typhoid fever. 
These are its distention by flatus, and ulcerations. The flatulent 
distention is present in a large proportion of cases. It is some- 
times very great, pushing up the Uver, the stomach, and the dia- 
phragm, much beyond their usual positions, and accounting for 
the extreme tympanitic enlargement of the abdomen during life, 
Louis found this meteorism of the large intestine most frequently 
present, and most strongly marked, in cases which terminated 
between the twentieth and thirtieth day. 

Ulcerations are found in about one-third of the cases. They 
were present in twenty-three of seventy-four examinations, made 
by Louis and Barth. They are generally small in size, more or 
less regularly rounded, not very numerous, more superficial than 
those of the smaU intestines, and occupying, most frequently, the 
cecum, though not confined to this portion of the large intestine. 
This lesion is most common in cases terminating late in the dis- 
ease. In a small number of instances, the sub-mucous cellular 
substance of the isolated foUicles is found to have undercrone the 
same yellowish transformation, that has already been spoken of, 
as occurring in the elliptical plates. 

The mucous membrane of th^ \::z~ '- rs: es is sometimes 
healthy throughout. At others, i: i^ : : ir . : ..ickened, or 
diminished in consistence. There is nothing, however, in these 
last mentioned alterations, in any way peculiar to typhoid fever ; 
since they are found as frequently in many other acute diseases, 
as in this. The contents of this portion of the alimentary canal 
are usually thin, and of a yellow, or greenish, color. 

As to the relation between the intestinal lesions, on the one 



LESIONS.— LARGE INTESTINES.— LYMPHATIC GLANDS. 77 

hand, and the various abdominal symptoms, on the other, I have 
but little to say. It \vould be unreasonable to suppose that such 
a relation does not exist. There can be no doubt, that the 
diarrhoea, and the abdominal pains, are connected with the different 
lesions of the intestinal canal. It is, nevertheless, sufficiently 
evident, that this relation is far from being constant and in- 
variable. In this, as in almost all other diseases, the violence of 
the symptoms, the perturbations and perversions in the functions 
of the disordered organs, are not to be measured, exclusively, by 
the appreciable pathological alterations, which may exist in the 
organs themselves. Other elements and other influences, many of 
them obscure and difficult to seize and to estimate, are concerned 
in the production of the symptoms. We thus find in typhoid fever, 
that although there may be a general relationship between the 
abdominal symptoms, and the intestinal lesions, sometimes the 
lesions are almost entirely latent ; they are not revealed by any 
characteristic symptom during life. Occasionally, extensive ul- 
ceration of the elliptical plates, with changes of the mucous mem- 
brane, may exist without giving rise to much diarrhoea, or to any 
other prominent abdominal symptom. 

Sec. V. — Lymphatic Glands. The glands of the mesentery 
are always found more or less changed; according to their posi- 
tion, and according to the period at w^hich the disease has ter- 
minated. Where death takes place before the expiration of the 
third week, they are increased in volume, diminished in consist- 
ence, and of a rosy, or red, color. If life is prolonged beyond 
this period, the volume is found more nearly natural, the soften- 
ing is less marked, and the red color is supplanted by various 
shades of gray, and violet. In some of them, there are found 
small yellow points of a purulent deposition. The diseased glands 
correspond, very nearly, to the altered elliptical plates ; those 
nearest the ileo-cecal valve being most changed in their appear- 
ance. In a few instances, the glands are moderately enlarged, 
softened, and reddened, opposite the upper plates of the intestine 
which continue healthy. 

The glands of the meso-colon are also affected in a similar 
manner, but less extensively and less constantly. The same ob- 
servation, with the same qualification, is true of the other lymphatic 



78 TYPHOID FEVER. 

glands of the body. It is also true, that these glands are rarely 
changed from their healthy state in any other acute disease. 

Sec. VI. — Spleen. The spleen is almost always more or less 
altered in its appearance. The most constant change consists in 
an augmentation of its volume. In many cases, it is three or four 
times as large, as it is in its natural state. It is, also, very gene- 
rally diminished in consistence. This softening is sometimes ex- 
treme, so that the'parenchyma of the organ is reduced almost to 
an inorganic, pulpy mass. The increased size of the spleen, and 
its softening, frequently exist together, but not always. The cases 
in which this happens most commonly, and in which the two 
lesions are strongly marked, are those terminating most rapidly. 
The color of the spleen is very often changed from its healthy 
appearance, though not so uniformly, as its volume and consist- 
ence. It is generally darker than natural, of a deep, bluish 
brown, and sometimes almost black. These changes of volume, 
consistence, and color, generally extend uniformly throughout the 
whole substance of the spleen. Louis found this organ in its 
natural condition, only four times in forty-six examinations. All 
the alterations, to which it is subject, are most strongly marked 
in those cases, which terminate before the thirtieth day. 

I'have avoided, for the most part, the elaborate discussion of 
questions relating to the nature and causes of the various lesions, 
which are found in typhoid fever. It may be well, however, to 
observe here, that these alterations of the spleen can hardly be 
attributed to any inflammatory action. The reasons adduced by 
Louis for this opinion, seem to me to be sufficiently satisfactory. 
Pus, the most unequivocal evidence of inflammation, is never 
found; the serous envelope of the spleen is unaltered; and the 
softening and enlargement affect uniformly the whole substance 
of the organ ; which, so far as all analogies enable us to decide, 
would not be the case, if these lesions were the result of inflam- 
matory action. In the present state of our knowledge, it is 
enough, perhaps, to say, that these alterations of the spleen, in 
typhoid, as well as in other fevers, hereafter to be described, de- 
pend upon some special and peculiar cause, connected with the 
diseases in which they occur, the nature and operation of which 
are unknown to us; and further, that the lesions seem to be asso- 
ciated with that pathological element, so obscure in its nature and 



LESIONS.— LIVER.— PANCREAS. 79 

causes, but so extensive and fatal in its results, to which the term 
congestion has been applied; and not with that other element, to 
which the term inflammation has been applied. 

Sec. VII. — Liver. The only alteration of any considerable 
frequency, in the liver, consists of softening. This existed in 
about one-half of Louis's cases; but inasmuch as it was found 
oftenest during the warm season, it may be, that to a considera- 
ble extent, at least, it is a cadaveric phenomenon, resulting from 
commencing decomposition. In a certain proportion of cases, 
the color of the liver is paler than natural, and it is less filled with 
fluids; less frequently, it is darkened and reddish, and mode- 
rately engorged with blood. Andral found the liver almost con- 
stantly heahhy.^ 

There is no constant or uniform alteration in the qualities of the 
bile contained in the gall bladder. Oftentimes, it is found red- 
dish, greenish, and abundant; at others, it is darker, of various 
shades, less liquid, viscid, and less abundant. Occasionally, the 
mucous membrane, lining the gall bladder, is manifestly inflamed, 
and the bladder contains pus. There is nothing in the condition 
of the liver, or of its secretion, at all peculiar to typhoid fever. 

Sec. Vni. — Pancreas; Salivary Glands; Urinary Apparatus ; 
and Sexual Organs. These several parts are generally found in 
a healthy state, and the occasional lesions, w^hich they exhibit, 
are such as occur in other acute diseases. 

The accurate and extensive researches of Rilliet and Taupin 
have shown, that the same anatomical lesions are found in patients 
under fifteen years of age, as in adults. The differences, in this 
respect, between the two classes of cases, are too few and unim- 
portant, to make it worth while to notice them in detail. The 
intestinal ulcerations seem to be somewhat less numerous, and 
extensive, than in adults; and a little later, perhaps, in their oc- 
currence. The yellow, hard, friable matter is rarely met with. 

* Andral's Clinique MecUcale, vol. iii. p. 579. 



80 TYPHOID FEVER. 

ARTICLE V. 

GENERAL RE3IARKS. 

Such are the conditions of the several organs and tissues of the 
body, in typhoid fever. It will be seen, from the detailed de- 
scriptions of these organs and tissues, which has just been given, 
that the lesions in this disease are numerous and profound. Its 
pathological anatomy corresponds, in complexity, variety, and 
extent, to its symptomatolog}^ There are, indeed, few, jf any, 
diseases, of an acute character, and of common occurrence, in 
which this complexity, variety and extent, of symptoms and 
pathology, constitute so prominent and so striking a feature, as in 
this. 

Some of the lesions, as has already been said, are more or less 
accidental; that is, they do not necessarily constitute any part of 
the pathological anatomy of the disease." They are not constantly 
present. Many of these, however, such as the changes in the 
mucous membrane of the stomach, and the alterations of the 
spleen, are of very frequent occurrence; and we have good rea- 
son to believe, play generally an important part, in the pathology 
of the disease. Other lesions are not accidental, but essential; 
necessary to the disease. They always enter into its composition. 
They make up one of its constituent elements. They are inva- 
riably present. This is the case with the alteration of the ellip- 
tical plates of the small intestine, and the lymphatic glands of 
the mesentery, corresponding to these altered plates. 

The real and relative importance of the several lesions, acci- 
dental and essential, is a question, in the actual state of our 
knowledge, not susceptible of absolute and positive settlem.ent. 
It is a very natural and philosophical conclusion, perhaps, that 
the essential and constant lesions are more important, than those 
of an opposite character. This is true, of course, so far as diag- 
nosis is concerned; so far as the fixing and identification of the 
specific disease is concerned: but it is very questionable, whether 
these lesions exert a more powerful influence upon the rapidity, 
and the danger of the disease, than some of the others. It seems, 
indeed, very probable, that in many cases, life is destroyed, or 
the disease is rendered dangerous and severe, by the successive 



LESIONS.— GENERAL REMARKS. 81 

development of these secondary alterations, rather than by the 
extent and gravity of the essential lesions alone. 

The order of succession, in which the several lesions commence, 
and are developed, is, also, a matter not susceptibleof very rigor- 
ous demonstration. Death almost never takes place, in the dis- 
ease, before the termination of the first week, and not often as 
early as this. Still, a careful study and comparison of the patho- 
logical appearances, which are presented in cases of differing 
durations, will enable us to arrive at a reasonably certain approxi- 
mation to the truth. There can be but little doubt, I think, that 
one of the first, probably the first, pathological alteration, which 
takes place in the solids, consists in the tumefaction of the ellip- 
tical plate, or plates, nearest to the ileo-cecal valve. This tume- 
faction is accompanied or followed by other changes, — an afflux 
of fluids, softening of the mucous coat, the hard, yellow transform- 
ation of the sub-mucous tissue, and, finally, by ulceration ; and 
these several lesions, taking place, first in the plates nearest to 
the ileo-cecal valve, gradually and successively extend to those, 
which are farther removed from it. (yotemporaneous, probably, 
or nearly so, with these alterations, are the reddening, enlarge- 
ment, and softening of the mesenteric glands. The enlargement 
of the spleen, and the diminution of its consistence, occur, also, 
there is good reason to think, in the early stages of the disease ; 
and the same thing is probably true, though less constantly, per- 
haps, of the softening of other organs. The various pathological 
changes, which are found in the gastro-intestinal mucous mem- 
brane, begin and are developed, it would seem, at uncertain and 
indefinite periods, during the progress of the disease. 

As to the relation which exists between these appreciable le- 
sions — one or many of them — and the disease itself, if we may so 
speak, I have but little to say. This is a question, which is 
wholly theoretical in its character. Its settlement, by different 
individuals, will depend entirely upon the mode of interpreting 
the phenomena of typhoid fever, and the relations of these pheno- 
mena, which they may choose to adopt. One thing, however, we 
may say, and that with great confidence, and without any quali- 
fication; to wit, that typhoid fever is not a gastro- enteritis. It 
may, correctly enough, be called a peculiar enteritis, or a dothinen- 
tentis, but not 3i gastro-enteritis ; and this, for reasons suflSciently 
obvious. I do not think, however, that we are justified in refer- 
6 



82 TYPHOID FEVER. 

ring typhoid fever, considered as a disease, — as an integral, though 
complex, pathological condition, and process or series of processes, 
— to this single local lesion of the intestines. I do not think, that 
we are justified in considering the latter, as the exclusive origin 
and cause of the former, as we consider acute inflammation of the 
mucous membrane of the large intestines the cause of that other 
disease, — that other integral pathological condition and process, 
or series of processes, which we call dysentery. The most strik- 
ing analogies are all against this interpretation. It seems to me 
much more satisfactory and philosophical, much more in accord- 
ance with what is seen in many other diseases, to look upon the 
lesion of the elliptical plates, not as the local cause of all the other 
appreciable phenomena of typhoid fever, but as constituting one 
of the pathological elements, in a very obscure and complex dis- 
ease ; all which elements, and this, quite as much as the others, 
are themselves the result of some morbific agent, or influence, or 
process, the nature, sources, and operation of which are wholly 
unknown to us. The lesion of the elliptical plates seems to me 
to bear somewhat the same relation to typhoid fever, considered 
as a disease, as that which their several characteristic eruptions 
bear to measles, scarlatina, and small-pox. In none of these, 
have we any right to regard the cutaneous eruptions, as the causes 
of the symptoms, and of the other various phenomena, which go 
to make up the several diseases themselves. I shall have occa- 
sion to refer to this subject hereafter. 



83 



CHAPTER IV. 

CAUSES. 

The only causes of typhoid fever, the influence of which has 
been at all positively and accurately ascertained, are these three, 
to \vit, — age; recent residence in a given place; and contagion. 
In using the word cause here, I mean merely to express by it 
some of those circumstances, or conditions, amidst which, the 
disease under consideration most frequently occurs. The nature 
and essence of the actual, producing, efficient cause of typhoid 
fever, as of most other diseases, are entirely unknown to us. 

Sec. I. — Locality. Typhoid fever is, evidently, a disease of 
very extensive geographical prevalence. We have not the means 
of ascertaining its limits, but there is good ground, I think, for 
believing, that these limits are wider, than those which circum- 
scribe the prevalence of any other strictly idiopathic, non-eruptive 
fever. It is the common fever of the Eastern States. It is ques- 
tionable, indeed, whether this section of the country is the seat of 
any other fever, unless it be an occasional sporadic case, or epi- 
demic, of an obscure and doubtful character. The extent of the 
prevalence of typhoid fever, in the New England States, may be 
judged of by the following statistics, derived from the bills of mor- 
tality for the city of Lowell, for a series of sixteen years, from 
1830 to 1846, inclusive. The entire number of deaths from 
typhoid fever amounted to four hundred and thirty-five. There 
was only one disease which occasioned a larger number, and that 
w^as consumption. The population of Lowell, during this period, 
increased, pretty regularly, from 6,477 to somewhat more than 
28,000. The number of deaths, from typhoid fever, annually, 
varied from five, in the years 1830, and 1831, to forty-four, in 
1839. From 1832 to 1846, the smallest number in any single 
year was sixteen. This was in 1841 ; in the preceding year, it 
was twenty-six ; in the following year, it was forty-three. In 



84 TYPHOID FEVER. 

1846, the mortality went up to one hundred and one. These 
statements serve to show, at the same time, the importance and 
frequency of the disease, and the variations in the extent of its 
prevalence in different years. ^ It prevails, also, more or less ex- 
tensively, in the Middle and Western States. I have often seen 
it in Kentucky, where it is sometimes called the red tongue fever. 
It is, probably, less common in those portions of the United States, 
which are visited by the various forms of intermittent and remit- 
tent fever, than in those which are exempt from these diseases; 
although more extensive and accurate observations, than have yet 
been made, are necessary to settle this point. Now that the 
means for correct and positive diagnosis of the several distinct 
fevers of our country are becoming more and more generally dif- 
fused, there is reason to hope that this, as well as some other cir- 
cumstances, in the natural history of typhoid fever, will soon be 
satisfactorily established. 

In December, 1846, I addressed letters to the editors of the 
Medical Journals, published in the Southern and Western States, 
inquiring particularly as to the existence, in their respective 
neighborhoods and regions, of typhoid fever. These letters have 
been promptly and kindly noticed, and they demonstrate very 
conclusively the prevalence, more or less extensive, throughout 
many portions of the Southern and Western States, of genuine 
typhoid fever, its symptoms and lesions correspondins^ exactly to 
the common continued fever of France and New England. The 
interest attaching to this subject induces me to make a few ex- 
tracts from this correspondence. 

Dr. Mattingly, of Bardstown, Kentucky, says that typhoid fever 
prevailed extensively in that town, during the fall and winter of 
1846. He enumerates the following phenomena as very con- 
stantly present in cases of moderate severity. " Chills ; increased 
local or general heat; accelerated pulse, generally about 100; loss 
of appetite; muscular debility; more or less diarrhoea ; pains in 
the bowels ; dullness of the intellect ; more or less delirium ; fre- 
quent epistaxis; dry, brown, or red tongue, trembling, and with 
difficulty put out of the mouth; rose- colored spots, or typhoid 
eruption; twitching of the tendons; a purplish flush on one side 
of the face, pasang over to the other in the course of two or three 

' An Address before tke Mass. Med. Soc. By Joim 0. Green, M. D. 



CAUSES.— LOCALITY. 85 

hours; a greater or less degree of tympanites; somnolence, or 
watchfulness; ringing in the ears, or deafness; one or two exa- 
cerbations of fever every day, constantly in the evening, some- 
times in the forenoon. These symptoms come on gradually, in- 
creasing in violence from day to day, for ten or twelve days, when, 
after remaining about at a stand for a few days, they gradually 
give way, and one by one pass off, till convalescence takes 
place." No one will doubt, I take it, the genuineness of the dis- 
ease thus described. Dr. M. treated, during the season, fifty-three 
cases. Of these, twenty-six were between fourteen and twenty 
years of age; eighteen, between twenty and twenty-five; and 
nine, between twenty-five and thirty. The average age was nine- 
teen years, and a half, nearly. There was hemorrhage from the 
bowels in nine cases. Death took place in five cases. There 
was one autopsy, showing ulceration of the elliptical plates, and 
redness and enlargement of the mesenteric glands. 

Dr. Sutton, of Georgetown, saw in his own town and neighbor- 
hood, during the year 1846, forty-three cases. He mentions a 
few trifling differences between his cases, and the disease as de- 
scribed in my book, but none of any importance. He made two 
autopsies, both of which exhibited the intestinal and mesenteric 
lesion. 

Dr. Wooten, of Lowndesboro', Alabama, says, — ''There are 
physicians in our state who contend that we have no fevers except 
those of a remittent or intermittent type. But my experience jus- 
tifies me in declaring this to be an error. Typhoid fever does 
exist here. It appears at all seasons of the year ; but I think it 
is most common in spring and early summer. Its occurrence is 
far more frequent of late years than formerly. In 1836, I saw but 
one case of it. In 1837, I had a very serious attack of it myself; 
I was seen by some half dozen experienced physicians, all of 
whom spoke of it as a very rare case. It has gradually grown 
more and more prevalent, until it is now looked upon as a rather 
common disease. It is unnecessary to describe the symptoms of 
this fever. It is sufl^cient to say that they are those described by 
you under the head of Typhoid Fever; and that it is unquestiona- 
bly the disease for which you inquire." 

I have a sensible letter from Dr. Core, who practices in Wil- 
liamson Co., Tennessee. There is one locality in his neighbor- 
hood, which, from the extensive prevalence of typhoid fever, 



S6 TYPHOID FEVER. 

within the last few years, has receiTed the name of typhoid 
bottom. 

Dr. Linton, editor of the St. Louis Medical and Surgical Jour- 
nal, in a short but excellent letter, says, — " The ferer, or rariety 
of fever, of which you speak, prerails here as in Kentucky, though 
I think it is not, either here or in that state, generally recognized 
as the typhmd fever. It is sometimes called winter fever, or nerv- 
ous fever, and sometimes it is not dignified with any specific 
r : ::: f . But of the fact, that we have here a continued fever, com- 
Lif: ::: r with chilly sensations, headache, and general malaise, 
r - 11 ; : ,:ed with diarrhoea, and more or less bronchial irritation , 
and exhibiting in its course, in many instances, the rose spots, or 
sudamina, or both, and running a course of fiom three or four to 
six or seven weeks, there can be no doubt. I have treated seve- 
ral such cases in this city." 

Dr. Leake, of Yazoo city, Mississippi, says the disease has pre- 
vailed more or less extensively, for several years, in his neighbor- 
tcri. 

Dr. Coe, of Dekalb Co.y Georgia, says, in a letter, dated March 
17,1847, — "About one year ago, an epidemic prevailed very 
generally over a small extent of country, which I determined to 
be typhoid fever. The section in which it prevailed had been 
previously healthy; it is elevated, with a poor soil, and has only 
one small stream passing through it. The locality of which I 
speak was about twelve or fifteen nules square, and almost every 
family, and nearly all the members of each family, except old per- 
sons and young children, were attacked by the fever. It was most 
extensive during May, June, July, and August. The number of 
cases amounted to two hundred. The following were amongst 
the most common symptoms : — Chills, more or less severe ; head- 
ache, with pain in the back and limbs, which subsided in a few 
days ; thirst, heat of the skin, acceleration of the pulse, and an 
evening exacerbation; entire loss of appetite; great muscular 
debility ; dullness and confusion of the intellect, passing gradually 
into delirium; great restlessness, subsiding just before day, :o 
some extent, to commence again about breakfast-time ; twitching 
of the tendons; picking at the bed-clothes, or at ima^naiy ob- 
jects; occasional epistaxis; ringing or buzzing in the ears; a dry, 
glutinous, cracked, red, or brown, or blackish tongue, protruded 
with trembling; dark, thick sordes on the teeth; diarrhoea, the 



• CAUSES.— LOCALITY. 87 

stools thin and watery, dark or yellowish, sometimes bloody ; tym- 
panitic state of the abdomen ; gurgling in the right iliac region on 
pressure. The disease was confined to persons between the ages 
of ten and forty years. There were twenty-two or twenty-three 
fatal cases." 

Dr. John P. Mettauer describes a continued fever of middle 
and southern Virginia. From 1816 to 1829, he treated more than 
four hundred cases. He says the disease prevailed in three forms, 
to wit, — those of synocha, typhoid, and typhus. Dr. Mettauer' s 
description of the disease is not sufficiently minute and detailed, 
to enable us to judge of the reality of these distinctions ; — the pro- 
babilities, however, are, that the disease was true typhoid fever, 
and nothing else.^ Dr. Austin Flint, of Buffalo, has published an 
account of the disease, as it prevailed at the little settlement of 
North Boston, in 1843. The disease seems to have been intro- 
duced by a traveller from Massachusetts. Of forty-three persons, 
constituting the entire population of the village, twenty-eight had 
the fever, between October 19th, and December 7th. Ten cases 
terminated fatally.^ 

Dr. Samuel Jackson speaks of its frequent and extensive preva- 
lence in the region of Northumberland, Pennsylvania.^ 

In the statement of deaths in New Orleans, for the last six 
months of the year 1844, forty-four are set down to typhoid/ever. 
In the Report of the New Orleans Charity Hospital, for 1844, 
ninety-two cases are classed as typhoid fever. '^ I do not know 
how confidently the diagnosis, in these cases, is to be relied upon. 

It would seem that the typhoid is the most common and gene- 
rally diffused fever of the temperate latitudes of the continent of 
Europe. Certainly it is so of France, where it has been most 
extensively and thoroughly studied. It seems to be also the 
common fever of Germany. In vol. xlviii. of the Edinburgh 
Medical and Surgical Journal, there is a notice of this disease, as 
it is described by several writers, prevailing at Brux in Bohemia, 
Dresden, Berlin, and at Stangenrod. Burserius describes the dis- 
ease very fully and accurately, under the title of slow nervous 
/ever J Louis saw it at Gibraltar, in 1828. It occurs with con- 
siderable frequency in the British Islands, although it is not their 

> Amer. Jour. Med. Sci,, July, 1843. 

2 Amer. Jour. Med. Sci., July, 1845. 3 Ibid., Oct., 1845 

< N. 0. Med. Jour., vol. i. pp. 390, 392. 6 Inst. Pract. Med. vol. i. p. 479. . 



TFPHOID FETXA. 



cf Sswei. The mcansy howeier, fiv aseertain- 
ing, iKilk any degree cf ^ecisHm,1tlieacl]ial eiteBl and firequencj 
cf ilis pievalence, in llie sereial pcxtians cf Gieat ^^iliain do nd 
exisit, fiir tibe obirkNis reaami, dial no distmedoii bas genexallf 
been naade, between dus disease, and Ibe oonla^^kiDs typbns. It 
jdU jmhaikity be fiiiaid to be cf moie eomnifm occurrence, in cer- 
tain potions of die couniij, daan in odios, and at catain seasons 
cr peiiods of time. Tbis sabjedt wSl necessai% come bef: t 
again in tbe aceoonliiiliidiiiiin begi^eiiaf 1^ inTesl^alic 
ba¥e been made, widnn tbe last lew jeais, in regaid to tbe 
tiltj, or tbe mm^idenlitj, of tf^os and tjpboid ferer. It ci 
^vnT^^TT^^ ^ §gjSj seldlkd, wsdiont 1^ aid oi obaerraiiiML^, tcjt 
zi :q extensile and diitrriminating^ dian bave jei b^een 

111 J 7 Ii If mean time, we can only ^qnosimale to the 

- — ::. ^0 lilie matter. Tjphaid lerer seems to bave r t i. 
^ ■ Dice at Dublin, fiom 1^6 to 1829. Dr. Kz- 

lt :: ir :::jad tbe eU^ftical patches raoie or less -s- 

\ _ T : r: ri <nf cases, during dus period, pres- . r 
1 s :£:i^ respect, to die contagious tjpi. 

iSai. Br —''In die epidemic ftf I82r : 

1^7, we : ^ O'^faliims, in tbe greater nc ii : - : 

of cases. I: _ :: ration took place, ani ±f 

Gooesp': - -T _ 
of die Frent- - 
.—••Hie intc : 



nt epi- 



r-_:-^\ 



.iLalioDS; and, in &1^ 
1- If iaidatedfiilL 



2 IbiiL 



CAUSES.— LOCALITY. 89 

the ileum, elevated and ulcerated, and the mesenteric glands, 
enlarged and softened. In four cases, perforation of the intestine 
had taken place. From the slight sketch of the symptoms, given 
by Dr. Reid, as well as from the abdominal lesions, there can be 
little doubt, I think, as to the character of the fever. ^ It would 
seem, also, to be very common at Birmingham. Dr. Ward has 
published an account of a fever, which prevailed in certain quar- 
ters of that city, in the summer of 1837, in all the fatal cases of 
which, the lesion of Peyer's glands is said to have been present. 
JMr. Henry Edmonston has published, in vol. xix. of the Edin^ 
burgh Medical and Surgical Journal, a short account of the pre- 
vailing fever at Newcastle-upon-Tyne, in the years 1821, and 
1822; from which it is quite evident, that the fever was typhoid. 
In vol. xli. of the same journal, there is a pretty full and valuable 
history, by Richard Poole, Esq., of what he calls an epidemic 
gastric fever, which prevailed in Limerick garrison, during the 
summer of 1833, and which was, clearly, typhoid fever. Nearly 
all the most characteristic symptoms of the disease were strongly 
marked. In the same volume, there is another history, by the 
same gentleman, of a similar epidemic, which prevailed at Tem- 
plemore, county Tipperary, Ireland, in the latter part of 1833. 

Dr. Stewart remarks, that during the summer and autumn of 
1836, the cases of typhoid fever received into the Glasgow Fever 
Hospital, were numerous ; while from the month of November, in 
that year, at which time both the type and the amount of typhoid 
fever became more formidable, till June, 1838, the period at 
which his connection with the hospital ceased, not more than a 
dozen cases, and these at long intervals, were admitted.^ 

Hillary, in his account of the diseases of Minorca, describes a 
slow nervous fever, which was, very evidently, typhoid. He says, 
*'The fever put on and appeared in this warm climate, with all 
the same symptoms, as it usually does in England ; and as they 
are accurately described by that learned and able physician Dr. 
Haaham, in the cooler climate of Plymouth. This slow nervous 
fever was certainly infectious, for I observed that many of those 
who visited, and most of them that attended, the sick in this 
fever, were infected by it, and got the disease, and especially 

' Edin. ]Med. and Surg. Journal, Oct. 1839. 
2 Edin. Med. and Surg. Journal, Oct. 1840. 



90 TYPHOID FEVER. 

those who constantly attended them, and performed the necessary 
offices for the sick."^ 

As to the influence of circumscribed localities upon the preva- 
lence of the disease, very little is known. It is sometimes absent 
from large sections of the country, for a considerable period of 
time. Nathan Smith says, that for the first eight years of his 
practice, which was somewhat extensive in the latter part of the 
last century, near the Connecticut river, in New Hampshire, he 
neither saw nor heard of a single case of the disease. Subsequent 
to that time, for a period of twenty-five years, he "never so far 
lost sight of the disease, as to be unable to follow its changes from 
one place to another, and to tell where it was prevailing." "It 
seems to possess," — he adds, — "a migratory character, and 
travels from place to place ; and after remaining in one village 
for a longer or shorter time, as, from one year to two or three, it 
ceases, and appears in another."^ It prevails often and exten- 
sively in the manufacturing villages of New England. This may, 
perhaps, be sufficiently accounted for by the circumstances favor- 
ing the occurrence of the disease, connected with the population 
of these villages. These are age, duration of residence, and ex- 
posure to contagion. In the city of Lowell, the largest manufac- 
turing place in the Eastern States, containing now, 1847, a 
population of somewhat more than thirty thousand, an unusual 
proportion of whom are between the ages of fifteen and thirty, 
and very many of whom are new residents, the disease has been 
almost constantly present, for the last twenty years. In some 
years and seasons, it has prevailed much more extensively, than 
in others ; and not unfrequently, for considerable periods of time, 
the cases have been occasional and few. It is a very common 
circumstance, for it to exist more extensively, in certain portions 
of the city, than in others. But there is nothing fixed in these 
localities; they are sometimes in one part of the city, and some- 
times in another. Instances have fi-equently been noticed, also, 
in various parts of the country, in which the disease is confined 
to a single family in a neighborhood. In these cases, several 
members of the family are sometimes taken with the disease nearly 
simultaneously; at others, they are affected in succession, one after 

' Rush's Hillary, p. 30, 44. 

2 Smith's Med. and Surg. 3Iemoir5. p. 46. 



CAUSES.— LOCALITY. 91 

another, so that the fever may occupy some months in passing 
through the family. Dr. James Jackson, of Boston, noticed this 
circumstance, particularly, in a paper in the New England Journal 
of Medicine and Surgery, for July, 1822. He supposes the cause 
to be in some way connected with the soil of the immediate locality, 
although not at all depending upon any filth, or decomposing sub- 
stances, since no such substances could be discovered, and since 
the houses were often new, clean, in good situations, and occupied 
by families in easy circumstances. He expresses his disbelief in 
the agency of contagion, although he says, that he has often known 
the disease to occur in friends, and hired nurses, who had gone 
from other families to attend the sick, especially when such per- 
sons have remained in the house with the diseased subject, for 
two or three days at least, and generally for a longer time. A 
remarkable example of the obscurity in which some of the causes 
of typhoid fever are enveloped, and of its singular and inexplicable 
connection, at certain times, with certain localities, was exhibited 
during the winter of 1834-5, in the city of Lowell. In the course 
of the winter, there were occasional cases of the disease, in almost 
every part of the city, but by far the greatest number occurred 
amongst the female operatives of a single cotton mill; and most 
of these, even, were confined to two rooms. This mill is situated 
on a line with five others, and in their immediate vicinity. It is 
about one hundred and fifty feet in length, and five stories high ; 
the rooms occupying the whole length and breadth of the mill, 
with numerous windows on every side. The ground room was 
used for carding, and the average number of hands employed in 
it was thirty-five. There was not a single case of the disease from 
this room. The second story was used for spinning. Four females 
employed in it went out sick during December; one on the 8th, 
9th, 10th, and 15th, respectively. The one who left on the 10th, 
died on the 27th of the same month. The average number em- 
ployed in this room w^as sixty. The third story was appropriated 
to weaving, and the average number of operatives employed in it 
was sixty-five. Between December 5th, 1834, and January 22d, 
1835, twenty-six girls left this room ; all of whom, excepting some 
three or four, were ascertained to have had the fever. They left 
the mill in the following order; one, Dec. 5th, two on the 11th, 
one on the 13th, one on the 18th, two on the 20th, two on the 



92 TYPHOID FEVER. 

21st, three on the 22d, two on the 23d, one on the 24th, 27th, 
and 31st, respectively. One left Jan. 5th, two on the 8th, two 
on the 9th, and one on the 10th, 12th, 21st, and 22d, each. The 
fourth story was used for the same purpose, and had the same 
number of employed hands, as the third. Between Dec. 13th, 
and Jan. 27th, eighteen girls left this room, sick. One left Dec. 
13th, one on the 17th, two on the 19th, one each on the 20th, 
22d, and 23d, two on the 24th, and one on the 27th. Three left 
Jan. 1st, and one on the 7th, 9th, 10th, 16th, and 27th, succes- 
sively. From the fifth story, occupied as a weaving room, and 
having from twenty-five to thirty girls employed in it, there were 
but two sick. One of these left the room Jan. 10th, and the other 
Jan. 17th. 

Thus, of one hundred and thirty females, employed in two rooms 
of the same building, nearly one-third were attacked with typhoid 
fever between the days of Dec. 5th, 1834, and Jan. 27th, 1835. 
Of this number, nine died in Lowell. There were also two deaths 
ascertained to have taken place, amongst those who left the city 
immediately on leaving the mill. During this period, there were 
a few cases of fever in various other parts of the city. Nothing 
could be discovered about the mill or the two weaving rooms in 
any way to account for the connection of so many cases with this 
particular mill, and these particular rooms. There was but a 
very small number sick from the neighboring mills. The over- 
seer of the room in the third story, where the largest number w^as 
attacked, informed me, that for nearly five years, during which 
he had had the care of the room, there had been amongst those 
at work in it only three deaths. The weather at the time when 
the fever began to show itself was extremely cold. There did 
not seem to be any connection between the disease and the situa- 
tion of the boarding houses of those who suffered from it. These 
houses accommodated from twenty to thirty girls each; in a few 
of them, there were two or three patients sick at the same time, 
but in many of them, only one. 

An instance of this connection of the disease with circumscribed 
localities, somewhat similar to the foregoing, took place in 1835, 
at a woollen manufacturing establishment on the Neponset river, 
in Dedham ; a short account of which was published by Dr. Jack- 
son, in the Boston Med. and Surg. Journal. On the 11th, and 



CAUSES.— LOCALITY. 93 

12th of April, eighteen girls, living in the same house, were 
attacked with typhoid fever; one of whom died. All these girls 
worked in one of two mills, near the house. From the other 
mill, there were no cases; and neither were there any cases, in 
the neighborhood, excepting those in this one boarding house. 
The entire number of its inmates was fifty-eight. The house had 
been built only eight years ; it was clean and not crowded ; and 
no death had ever taken place in it, till about a week before the 
appearance of these eighteen cases of fever. On the 5th of April, 
a girl from the same mill with the others, died after an illness of 
nearly three weeks, with what was at first considered by her phy- 
sician. Dr. Spear, as scarlatina ; but which he regarded subsequently 
as typhoid fever. All the females who were attacked on the llth^ 
and 12th of April, had seen this first patient ; some of them, how- 
ever, only after death. In May, another girl had the fever ; not 
an operative in the mill, but a domestic in the boarding house. 

Dr. Wooten of Lowndesboro', Alabama, in a letter to me, upon 
the subject of typhoid fever in his neighborhood, says, — "There 
is a circumstance connected with its prevalence here, worthy of 
note. We have a high ridge of land, possessing a sandy and 
gravelly soil, which aflfords many springs of good free-stone water, 
and is selected by many planters, who occupy the surrounding 
country for their residences. This ridge is about six miles long, 
and from one to three miles wide, and at its nearest point about 
three miles from the Alabama river. It is surrounded by prairie 
plantations and prairie sloughs on all sides except that towards 
the river, where it is bordered by a low, pondy, and malarial 
country. In all the surrounding country, intermittent and remit- 
tent fevers are an annual matter of course occurrence, whilst the 
true typhoid is extremely rare, though cases of it do sometimes 
occur. But upon the ridge, where remittents and intermittents 
are of very rare occurrence, the typhoid cases are of frequent 
occurrence, especially during the last few years; so that many 
planters say they would prefer remaining on their plantations, 
and having their regular turn of chills and fever, to residing on 
the ridge, and risking this slow fever. ^"^ 

There is a pretty common opinion that typhoid fever has a tend- 
ency to come in and take the place of intermittents and remittents, 
as these diseases, from the effects of cultivation and from other 
causes, diminish and disappear. Dr. Austin Flint, of Buflfalo, 



94 TYPHOID FEVER. 

says, — " That typhoid feTcr has, to a great extent, superseded the 
remittent form, has been a matter of frequent remaik fiir some 
time ; and in a brief enumeration of the distinctive traits of remit- 
tent, typhus, and typhoid feTer, published bjns in the fiist volume 
of this journal, we mentioned this as a sentiment generallj enter- 
tained by the profession in this r^on. That some allowance is 
to be made fiom the feet already referred to, that the boundary 
lines between the two forms, are now much more clearly drawn, 
and have been rendered more familiar to practitioners, we regard 
as highly probable; yet we think there cannot be a doubt that a 
striking change has taken place within a few years past, and that 
typhoid fever, from having been, to say the least, of unfrequent 
occurrence, has become frequent, and is becoming more and more 
so, remittents *liwiifiishing in frequency after the same ratio."* 

These views are corroborated by some conclusions to which M. 
Boudin has recently arrived. He says that there exists an antago- 
nism between typhoid fever, on the one hand, and intermittent 
fever, and phthisis, on the other. ** Those localities," — he says, — 
" in which the producing cause of endemic intermittents tborougfa- 
ly modifies the constitution axe remarkable fia- the infrequency of 
pulmonary phthisis, and typhoid fever. The localities in which 
phthisis and typhoid fever are particularly prevalent, are re- 
markable for the infrequency and mildness of intermittent fevers 
contracted on the spot. The drying up of a marsh, or its con- 
version into a lake, diminishes or prevents intermittent fevers, but 
seems to dispose the organism to a new series of diseases. *l 
which pulmonary phthisis, and typhoiil fever, according to ::.r 
climate, are particularly prominent. After a residence in a ::. - 
roughly marshy locality, an individual enjoys an immunity f:: ii 
typhoid fever, the degree and duration of which are in direct piiv 
portion to the length and degree of the exposure."* 

Sec. n. — Seasoii. It is not settled how far typhoid fe^^er ''"- 
curs, with any degree of uniformity, more frequently in •:::- s : - 
son of the year, than in another. The common impress :. 
New England, is, that it prevails oftenest in the autum: I 
James Jackson says, expressly, that such is the fact; altL: _ . r 
admits that it maybe seen in any month of the year. Na!:. ::. 

> BaSEako Med. Joom, Feix IS47. * leaOaa Lancet, l&mii, 1847. 



CAUSES.— LOCALITY.— CONTAGION. • 95 

Smith does not speak of its occurrence more frequently at one 
season, than at another, and he thinks that he has seen it, not 
only in every month, but in every day of the year. Amongst the 
epidemics mentioned by Gendron, one continued from May to 
October, one from February to May, and one from March to Janu- 
ary. The most extensive and fatal visitation of the disease, in 
the city of Lowell, took place during the winter and early spring. 
I am very sure, however, that, as a general rule, its annual pre- 
valence is greatest in the autumn. In New England, it is not 
unfrequently called the autumnal or fall fever. In the Richmond 
epidemic of 1840, the first case occurred on the 22d of August; 
there were, in August, six cases; in September, seventeen; in 
October, ten; in November, six; in December, and January, 

1841, each, two; and in February, three, — the last case com- 
mencing on the 28th of this month. The disease then disap- 
peared till the 16th of August, 1841, when it returned. There 
were, in August, four cases; in September, six; in October, 
eighteen ; in November, seven ; in February, 1842, one ; in 
March, seven; in April, one; and in May, two. From May 3d, 

1842, to August 4th, there w^as no new case. The disease then 
reappeared, and there were, in August, three cases; in September, 
two; and in October, one. 

One hundred and eighty-three cases at Strasbourg were dis- 
tributed amongst the four seasons in the following manner, to 
wit: — spring, thirty-eight; — summer, forty- nine; — autumn, sixty; 
winter, thirty-six.^ 

Sec. III. — Contagion. The general opinion has been, that 
typhoid fever is not propagated by contagion. Louis, in his first 
edition, published in 1829, says nothing upon this subject. Cho- 
mel, in his Lepons de Clinique Medicale, published in 1834, al- 
though he, himself, w^as inclined to the opposite opinion, says that 
not more than one physician of a hundred, in France, regarded 
the disease as contagious. Andral says he never saw any evi- 
dence of its contagiousness. Dr. James Jackson says, if he were 
to answer from general experience, he should say that instances 
occur, in which there is much in favor of the doctrine of conta- 
gion ; but that in the very great majority of instances, there is not 

' Traite de TEnterite Folliculeuse. Par C. P. Forget, p. 409. 



96 TYPHOID FEVER. 

any such evidence. He relates some cases, occurring amongst 
the hospital nurses, apparently attributable to contagion.^ In 
1829, M. Bretonneau read to the Royal Academy of Medicine a 
paper, intended to show, that the disease as it prevailed in the 
country, was often transmitted from one individual to another. 
Leuret, about the same time, adopted a similar opinion. The 
subsequent researches of Gendron, Ruef, Putegnat, and others, 
have confirmed this opinion, and Louis has adopted it in the 
second edition of his work, published in 1841. Many years, 
however, previous to these publications, Nathan Smith asserted, in 
the most positive and unqualified terms, the contagious character 
of this disease. His essay was published in 1824. " That the 
typhus fever is contagious," — he says, — " is a fact so evident to 
those who have seen much of the disease, and who have paid 
attention to the subject, that I should have spared myself the 
trouble of saying anything in regard to it, did I not know that 
there are some physicians in this country, who still dispute the 
point; one which, I think, can be as fully demonstrated, as that 
the measles, small-pox, and other diseases, universally allowed to 
be contagious, are so."^ Dr. Smith then mentions several in- 
stances, which had fallen under his own observation, where the 
disease seemed to have been communicated, through the medium 
of a contagious principle. From amongst these, I select the fol- 
lowing. " A young man, a pupil of mine, was attacked with the 
typhus fever, from which he recovered with some difficulty. Some 
of his family, who lived about forty miles distant, came and took 
care of him during his sickness. Upon his recovery, they returned 
home, in good health, but soon after sickened with the same dis- 
ease, and communicated it to others, who had not been exposed 
in the first instance. From this, it spread to numerous other 
families in the vicinity, who had been exposed to the contagion. 
In the whole town where this occurred, there had been no case 
of tj-phus fever for many years, till brought there by the circum- 
stance above related." 

"During the prevalence of the typhus fever in Thetford, Ver- 
mont, a woman went there from Chelsea, about ten miles distant, 
to visit and administer to a sister sick of this disease. Upon her 
return, she was herself attacked by it, and soon after died. 

. * Report, &C.J p. 144. * Smith's Med. and Surg. Memoirs, p. 47. 



CAUSES.— CONTAGION. 97 

Others of her family contracted it of her ; and in about four 
weeks, there were thirty persons taken down with typhus, all of 
whom had been exposed to tlie contagion."^ Dr. Samuel Jack- 
son, formerly of Northumberland, relates several striking instances, 
similar to those quoted from Nathan Smith, showing the contagious 
quality of the disease.^ 

The memoir of M. Gendron, upon this subject, is very full and 
elaborate. He adduces a great ifumber of instances, similar to 
those above quoted from Dr. Smith, many of them very striking 
and conclusive, to show the contagiousness of the disease. He 
believes that it is transmissible by direct and repeated contact ; 
by the presence of the sick, without contact ; that it may be car- 
ried from a sick person, and communicated to another by a third, 
who does not have the disease; and, also, that it may be con- 
tracted from exposure to infected clothing, beds, and similar 
fomites. He regards the first mentioned mode of transmission, 
as altogether the most common. The indirect transmission of the 
disease from one individual to another, through the intervention 
of a third, he thinks does not often happen, except when it is pre- 
vailing more or less extensively, as an epidemic. The disease is 
most frequently communicated to those who are in the closest and 
most constant relation to the sick, — their nurses, and immediate 
attendants. 

According to the observations of M. Gendron, typhoid fever 
propagates itself very slowly by contagion. The interval be- 
tween the successive cases varies from three weeks to a month ; 
so that the fever is often several months in spreading through a 
village, or neighborhood. The period of incubation, he thinks, 
rarely exceeds eight or ten days, though it sometimes extends to 
fifteen, and is occasionally as short as twenty-four hours. He is also 
led to the conclusion, that the power of transmission, or commu- 
nication, does not exist in the early period of the disease ; that it 
is rarely active before the sixteenth day ; and, in general terms, 
that it continues from the third week, to an indefinite period, in- 
cluding convalescence. He states some facts, which seem to 
show, that the contagious matter of the disease may remain active 
in a bed, for two or three years. He supposes it probable, that 
certain circumstances, connected with the disease in the country, 

* Smith's Med. and Surg. Memoirs, pp. 47, 84. 
2 Amer. Jour. Med. Sci., Oct. 1845. 



1 



98 TYPHOID FEVER. 

such as small, close rooms, and the more constant presence of 
their attendants with the sick, may render its contagious charac- 
ter more obvious and certain there, than in cities. He acknow- 
ledges, that in many instances, he has been wholly unable to 
ascertain the source and origin of the first case, from which the 
others have been derived; and he admits, in their fullest extent, 
the great number of examples of immunity from the disease, 
after the most marked exposure ,' but he says, very truly, that al] 
this is as frequently seen in scarlatina, a disease unquestionably 
contagious, as it is in typhoid fever. 

It is easy to see that this question is one of great practical im- 
portance. It can be fully settled only by further and more various 
observations ; and these observations, for obvious reasons, can be 
best made amongst the scattered population, and in the small vil- 
lages of the country. The paper of M. Gendron is drawn up 
with great fairness, and it throws much new and valuable light 
upon the subject; although he sometimes adopts conclusions, 
favorable to his opinions, which his facts are hardly sufficient to 
justify. He is somewhat too ready, in the present state of our 
knowledge, to consider all cases of the disease, that are in any 
way susceptible of being accounted for by the action of a con- 
tagious principle, to be, certainly and necessarily, so accounted for. 

Sec. IV. — Exemption from Second Attacks, There is one other 
circumstance, bearing upon this question, w^hich it is important to 
notice. I mean the immunity from a second attack, which seems 
to be conferred, by the occurrence of the disease. M. Gendron 
gives several remarkable instances of this exemption. The vil- 
lage of Petit-Genes, containing only fifteen persons, was visited 
by typhoid fever, in 1826. Twelve of these persons suflfered from 
the fever, and of the three who escaped, two had had it previously. 
In March, 1829, the disease reappeared in the village, apparently 
introduced by contagion, and was confined to a single family, 
who had taken up their residence here, subsequent to the year 
1826. Five members of this family had the fever, and although 
they were constantly visited, and nursed during the nights, by 
their neighbors, the subjects of the disease in 1826, the fever did 
not extend beyond the family.^ Chomel says, that of one hundred 

' Memoir sur les epidernies des petites localites. Par M. Gendron. Journal des 
Connaissances Medico-chirurgicales. Annee, 1834. 



CAUSES.— EPIDEMIC INFLUENCES. 99 

and thirty patients, at the Hotel Dieii, no one, so far as this point 
could be ascertained, had previously had the disease. 

The same immunity was noticed by Nathan Smith. He says, 
— "My own personal experience is strongly in favor of the opinion 
I have advanced of the non-liability of the same individual to a 
second attack of typhus; for during the twenty-five years, since I 
first attended patients in this disease, and in that time I have 
visited many hundreds, and have witnessed its prevalence several 
times in the same village, I have never known nor heard of its 
recurrence in the same person. 

" I once attended a numerous famil}^, every member of which 
was sick of typhus, except two, who escaped at that time ; but 
two years afterwards, when the disease again appeared in that 
neighborhood, those two individuals of the family, and those alone, 
were attacked. 

"In another family, which I attended, consisting of eight persons, 
five of the eight had the disease during the autumn, and early 
part of the winter, and recovered. The next summer, the remain- 
ing three and another person, who had been added to the family 
after the former sickness, were attacked by it, while all those pre- 
viously affected escaped."^ In 1840, there was an extensive local 
epidemic of typhoid fever, in the town of Richmond, Berkshire 
county, Massachusetts. It was carefully observed by Dr. Jen- 
nings; some of the cases were seen by Dr. Alonzo Clark, one of 
the most accurate and accomplished diagnosticians in the country, 
so there could have been no doubt as to the true character of the 
cases. The epidemic reappeared in 1841, and three of forty-six 
persons suffered with a second attack of the fever. There were 
forty-six cases, during each year.^ It need hardly be said, that 
this character of typhoid fever, if fully established, although not in 
itself positive evidence, does nevertheless constitute a strong ground 
of belief, resting on analogy, for the contagious nature of the dis- 
ease. 

Sec. V. — Epidemic Influences. Typhoid fever occurs both in 
a sporadic and epidemic form. Single, isolated, cases are not 
unfrequently met with ; extensive regions of country are some- 
times entirely exempt from the disease, for considerable periods 

' Smith's Med. and Surg. Memoirs, p. 52. 
2 Dr. Jennings" Letter to Prof. Clark. 



100 



;; smI, agaiii7ilafii»ptei»ls,astbav€alread|'liad 
mm to sajF, eidicT in arcMMMascnbeA ii0^ilMiriiDod% or iiwer 
m^es cf eomitiy, so genenlfy and estfaisivelf as to asanae an 
cpidendc dfiaiaeter. Tlic dkea^ in lOds cpUenk inn, as I 
liaTe brfbre ai^alted, beranfs ni^KriNHj m its dbaiadter, irandcr- 
iag^ aboirt ftc comiliy, affltadoj^ OM w^h^ 
Iher Uiie nest, and so on. It fieqnolfy b^ipcns Ibat Ac disease 
ielani%alneail]r1dbe ame season, to Ac sane locafilj, fir two 
cr tinee yeara in snccesaon, and Iftcm wlnllj disafipcais. 



Sec.TL-^%k. TTieinflm!w«rf^pintaM'pmidoclion,crpeT- 

/: ; - M T j^nnisacii . : f "~^Ti : ~ t 7 is "way ^tttiilting^ and "woj' 
^V7erfain-?-£ 5t-::^ - : . . t . 5^r Ae noBfiitt, Ac cadhf 



: _i z i : - : ;:. r " - r f 7 " 7 :. ' ? t . _ . _" t€:i- and twcBlj- 

fire. I~ .5 -It fe'w cases 

-. :r:::.7 . - : ^: -::. wt. Of 



CAUSES.— AGE.— SEX. 101 

of age. I once saw an unequivocal case in a country-woman, 
sixty-three years old. M. Lombard, of Geneva, relates a case 
occurring in a woman seventy-three years old.^ 

The opinion which I expressed above, in the first edition of my 
book, finds a striking corroboration in Dr. Jennings' account of 
the epidemic at Richmond, Berkshire county, Massachusetts, in 
1840, 1841, and 1842. The whole number of cases, during this 
epidemic, was ninety-eight ; and the average age was thirty-two 
years and two-thirds, although in this number are included nine 
children, from five to twelve years old. Forty-five, nearly half, 
were thirty-five years old, or over ; forty-one were forty years old, 
or over; twenty-one were fifty years old, or over; and eight were 
sixty years old, or over. The oldest was seventy-one.^ 

Amongst the young, typhoid fever occurs most frequently be- 
tween the ages of nine and fourteen years. From five to eight, 
it is less frequent; and still less so, at an earlier period. Of one 
hundred and twenty-one cases reported by Taupin, ten were in 
children not over four years old ; one case occurred at two years ; 
a few, earlier than this ; and one, at seven months. 

Sec. VII. — Sex. The influence of sex in the production of 
typhoid fever is not determined. Nathan Smith did not notice 
any difference in the liability of the two sexes. Dr. James Jack- 
son expresses his belief, that the disease occurs amongst men, 
much more frequently than amongst women. M. Tardieu ob- 
served, that at the village of Ventenges, in France, in 1835, 
women and children were most frequently attacked. M. Ruef 
says, that in the epidemic of Bischoffsheim, in 1832, females suf- 
fered more extensively than males. These facts may, perhaps, 
be accounted for by the more frequent and constant exposure to 
the sick, to which females are subject, in their capacity of nurses 
and attendants. Of ninety-eight cases, occurring at Richmond, 
Massachusetts, thirty- eight were amongst males, and sixty 
amongst females. Of Barthez and Rilliet's one hundred and 
eleven children, with the disease, eighty were boys, and thirty- 
one, girls ; of Taupin's one hundred and twenty-one cases, eighty- 
six were amongst boys, and thirty-five amongst girls. 

* Rep. Ann. de la Soc. Med. de Geneve, 1843, p. 21. 
2 Dr. Jennings' Letter to Professor Clark. 



102 TYPHOID FEVER. 

Sec. VIII.^ — Race. Whether the liability to typhoid fever is in 
any degree influenced by race, or not, I am unable to say. I have 
often made the inquiiy of practitioners in Kentucky as to the 
comparative liability of the two races to the disease, but without 
any satisfactory result. Dr. ^lattingly, of Bardstown, is inclined 
to think that nesrroes are somewhat less subject to the disease 
than whites. Dr. Sutton, of Georgetown, Ky., saw in 1846, 
forty-three cases ; thirteen of these were amongst negroes.^ 

Dr. Lewis, of Mobile, says,— "In the winters of 1835, 1836, 
and 1837, hundreds of negroes died of a low typhoid fever in the 
middle part of Alabama. All infectious diseases, which prevail 
usuallv in winter and spring, attack them more violently than 
the whites."^ 

Sec. IX. — Occupation. There is no evidence that any occu- 
pation or profession in itself in any way predisposes to this dis- 
ease, or preserves from it. 

Sec. X. — Recency of Residence. The researches of Louis and 
Chomel show, conclusively, that, in the city of Paris, typhoid fever 
occurs more frequently amongst new, than amongst old, residents. 
This difference is verv sreat. Of Louis's one hundred and twentv- 
nine patients, all but twenty-seven had resided in Paris only 
twenty months, or less; forty-four only five months, or less; and 
only four had resided there from infancy. Of Chomel's ninety- 
two patients, at the Hotel Dieu, forty-five, almost one-half, had 
resided in Paris only one year, or less ; and only two had lived 
there fix)m infancy. I do not know whether this influence has 
been noiiced in our own cities. In the city of Lowell, the dis- 
ease has generally attacked those who have not been long resi- 
dents there; but it would not be safe to rely upon this fact alone, 
since a large part of the young population of that place Have been 
residents, at most, for only a few years. It is very certain, I 
think, that the influence, now under consideration, cannot be so 
obvious in the country', as in large towns and cities. No notice 
is taken of it by that sagacious and careful observer, the late 
Nathan Smith. I have known the disease to prevail extensively, 
and in a very grave form, amongst the permanent residents of a 

* Letters to author. - X, 0. !Med. Joum^ voL i. p. 417. 



CAUSES.— FILTH, CROWDING, ETC.— EXPOSURE, ETC. 103 

country village. This, indeed, is a frequent occurrence in the 
agricultural regions of our Eastern states, and of France, where 
the population is generally native and fixed. 

Sec XL — Filth, crowding, Sfc. In regard to the action of 
putrid substances, and to the influence of scanty and unhealthy 
food, it is sufficient, perhaps, to say, that there is no satisfactory 
evidence of their operation, in giving rise to the disease. 

Piorry is of the opinion, that a majority of the patients in the 
Paris hospitals, are received from small and poorly ventilated 
lodgings ; but the influence of this cause in giving rise to typhoid 
fever is not generally admitted, and certainly does not seem to be 
very evident.^ 

Sec XII. — Exposure; Excesses, ^'c. The effect of what are 
usually regarded as the most common exciting causes of many 
forms of disease, such as exposure to cold, strong moral impres- 
sions, errors of diet, and excesses, is not very obvious, in the pro- 
duction of typhoid fever. Of one hundred and fifteen patients, 
at the Hotel Dieu, w^ho were examined by Chomel upon this 
point, seventy-nine were wholly unable to refer the access of the 
disease to any appreciable cause. It may be added, further, that 
persons suffering from the disease are, generally, immediately 
previous to the attack, in full health. 

^ Clinique Medicale de THopital Pitie. Par P. A. Piorry, p. 175, et seq. 



104 



CHAPTER V. 

VARIETIES AND f 0R:\15. 

Typhoid fever, like almost all diseases, exhibits many Tarieties 
in its character and appearances, some of which, before proceed- 
ino- to speak of its diagnosis, it is important to notice. One of 
these varieties depends upon the degree of severity of the disease. 
Louis divides his cases into three classes; consisting, first, of 
those which terminated fatally ; second, of those which were 
grave and severe, but which recovered; and, third, of those 
which were mild. It is obvious enough, that this arrangement is 
somewhat arbitrary; that the several degrees of severity must run 
off, by imperceptible gradations, like the colors of the spectrum, 
into each other; and that, oftentimes, the line of demarkation 
between the classes must be shadowy and doubtful. Neverthe- 
less, the distinction really exists ; in a great majority of cases, 
there is but little difficulty in recognizing and appreciating: it; and 
it is one, not only of convenience, but of great practical value 
and importance. 

It is a very common occurrence, for nearly all the more grave 
and alarming symptoms of the disease to be absent, from its com- 
mencement to its termination in health; and where its diagnosis 
is not well understood, these cases are often mistaken for some 
other disease. Under these circumstances, there is, frequently, 
but slight febrile excitement ; little or no thirst ; no affection of 
the mind; no diarrhoea; no pains in the abdomen. The patient 
sleeps well, the tongue may be nearly clear, slightly sticky, or 
covered only with a thin, brownish coat ; there is little or no rest- 
lessness, or suffering of any sort, and the patient wonders why he 
is sick, and why he is obliged to lie in bed. But he is obliged to 
lie in bed. Place him in his chair, and he very soon wishes to 
get back to his bed. On assuming a sitting or upright position, 
he finds that he does not feel so well ; his muscular strength is 
gone ; his debility, though not extreme, is out of proportion to 



i 



VARIETIES.— LATENT FORM. 105 

his other symptoms; and he is troubled, perhaps, with dizziness, 
or ringing in the ears. It will be found on inquiry, that, either 
suddenly, in the midst of good health, or after a few days of 
Tague and indefinite not heing well, the patient was attacked with 
a chill, accompanied or immediately followed by pains, generally 
of moderate severity, in the head, back, and limbs. JYone of 
these symptoms are accounted for, by any local disease. In the pro- 
gress of the fever, the headache goes off; there may be some de- 
gree of deafness; slight somnolence; occasional epistaxis ; and, 
during the second week, the lenticular, rose-colored eruption will 
probably show itself upon the abdomen and the chest. In this 
class of cases, after the condition thus described, has continued 
with but little change, during a period of from two to three weeks, 
the strength and appetite begin to return, convalescence is rapid, 
and the patient is soon restored to sound health. 

Between this, the mildest form of the disease, and those of the 
gravest and most dangerous character, there are, of course, all 
possible gradations. It is not necessary to describe them, parti- 
cularly. They are marked, in different degrees, by greater pros- 
tration of strength ; somnolence, followed by or alternating with 
delirium ; twitching of the tendons ; picking at the bed-clothes, 
or at imaginary objects; a dry, cracked, trembling tongue, red, 
brown, or black ; tympanitic distention of the abdomen, and 
diarrhoea. 

Dr. Jackson speaks particularly of the predominance of certain 
symptoms during certain periods of time. In 1828, and 1829, 
for instance, he had eleven successive cases, in nine of which 
there was dry tongue ; in 1831, this symptom was present in eleven 
of fifteen successive cases ; in 1834, in ten of twelve successive 
cases; and in 1835, in twenty-two of twenty-seven successive 
cases. At one period, epistaxis was very common ; at another, 
watchfulness, and so on.^ 

There is another phasis, under which the mild form of typhoid 
fever sometimes presents itself, to which Louis applies the term 
latent. The disease, in this form, cannot be called absolutely 
latent, though it is nearly so. The local lesion of the intestine 
is present ; in some cases, it is positively ascertained to have 
been extensive and profound ; but the disturbance and perturba- 

* Report, &c., p. 136. 



106 TYPHOID FEVER. 

tion of many of the functions of the economy, usually accompa- 
nying this lesion, and constituting the rational symptoms of the 
disease, do not take place, or rather they are very obscure. The 
reason of all this is entirely unknown, and the most we can say 
about it is, that the same thing occasionally happens in other 
diseases. The latent form of typhoid fever, like the ordinary 
forms, is commonly marked at its commencement by chills, head- 
ache, and moderate febrile excitement. But the patient is often 
able to sit up, or even to keep about, and there are no prominent 
symptoms of disturbance in the nervous system, or the abdomen. 
It is very curious, as has already been observed, that the cases of 
perforation of the intestine have generally been found to occur in 
this variety of the disease. 

All these different degrees in the severity of typhoid fever are 
frequently witnessed at the same time, during its prevalence in a 
given place. But it often happens with typhoid fever, as it does 
with many other diseases, — w^ith the bilious remittent, with true 
typhus, with scarlatina, with pneumonia, and so on, — that during 
one season, and in one locality, its prevailing character will be 
mild, and its mortality small ; while in another season, its charac- 
ter will be grave, and its mortality large. Dr. Power, of Balti- 
more, informs me in a private letter, dated September 4th, 1847, 
that typhoid fever has been epidemic in that city for the last four- 
teen months, and that it has exhibited more of the adynamic cha- 
racter than usual, and requiring a more stimulating treatment. 
I have, more than once, seen the disease pretty extensively pre- 
valent, when nearly all the cases belonged to the mildest form. 
In the epidemic of the city of Lowell, during the winter and spring 
of 1834-5, the cases w^ere generally grave, and the mortality con- 
sequently great. This difference in the severity of the disease 
during different years is very strikingly shown in the records of 
the Massachusetts General Hospital. During fourteen years, 
from 1822 to 1835, inclusive, there were three hundred and three 
cases of typhoid fever, and forty-two deaths ; or one in a little 
more than seven. In the year 1830, the deaths were one in three 
and a half ; in 1831, they were one in fourteen and a half ; and 
in 1829, one in twenty-five. From 1832 to 1835, inclusive, the 
number of cases was one hundred and twenty-nine, and the num- 
ber of deaths twenty-two, making a mortality of one in a little less 
than six; while from 1836 to 1838, inclusive, the number of cases 



VARIETIES AND FORMS. 107 

was one hundred and eight, and the number of deaths seven, 
making a mortality of one m fifteen. It is still more remarkable, 
that from November, 1836, to November, 1838, there were fifty- 
five successive cases, without a single death ! It may be added 
here, that these wide differences in the mortality and severity of 
the disease, in different years, are not to be accounted for, by any 
differences in the treatment.^ 

Chomel admits several forms or varieties of typhoid fever, not 
depending upon degrees of severity. These are ihe inflammatory, 
the bilious, the mucous, the ataxic, and the adynamic. They de- 
pend upon the relative severity, or predominance, of certain symp- 
toms, or groups of symptoms. In the inflammatory form, there 
are unusual strength and fullness of pulse ; great heat and moist- 
ure of the skin, urgent thirst, and diminished secretion of urine. 
These symptoms are especially prominent, only in the early pe- 
riod of the disease, xlccording to Chomel, they occur oftenest in 
the robust, and during the winter months. The bilious variety is 
characterized by some yellowness about the lips and nose ; a thick, 
yellowish, or greenish coat on the tongue; a bitter taste; nausea, 
and bilious vomiting. Chomel regards this form of typhoid fever, 
which occurs oftenest, he thinks, during the summer and autumn, 
and in particular localities, as identical with the bilious fever of 
authors. There is no doubt, whatever, that in the confusion 
worse confounded, which has always prevailed throughout the 
medical world, in relation to the diagnosis of fevers, and which is 
even now but very partially dissipated, typhoid fever has often 
been described under the name of bilious fever; but it is also quite 
certain, that if Chomel supposes typhoid fever and bilious remit- 
tent fever to be identical diseases, he is widely mistaken. It is 
easy to see, that there may be a bilious variety of typhoid fever, 
just as there is a bilious form of pneumonia. The mucous variety 
of typhoid fever is not very distinctly characterized, even in Cho- 
mel's description of it. It can hardly be said to exist, as a dis- 
tinct variety. The term ataxic is applied to those cases, in which 
there are great severity and predominance of the nervous symptoms, 
such as dullness, stupor, perversions of the senses, delirium, and 
spasms ; or to those in which the disease is masked, and rendered 
irregular, by a want of the usual correspondence in degree of 

> Hale on the Typhoid Fever of New England. Communications of the Mass. 
Med. Soc, vol. vi, part iii. pp. 254, 255. 



108 TYPHOID FEVER. 

severity between the more important symptoms. In these cases, 
there may be little or no delirium, or the pulse may be almost 
natural when the disease is manifestly hurrying on to a fatal ter- 
mination. The adynamic form is marked by extreme debility, 
and prostration of strength, present at the commencement, or 
coming on in the course of the disease. The mind is lethargic ; 
the pulse is feeble and soft; the urine, and the cutaneous transpi- 
ration, are fetid, and the disease is often prolonged beyond the 
fourth week.^ 

* Chomel's Le§ons de Clinique Medicale, p. 340, et seq. 



109 



CHAPTER VI. 

DURATION, MARCH, AND COMPLICATIONS. 
ARTICLE L 

DURATION. 

It is not often an easy matter to determine, with accuracy, the 
duration of a disease. Both extremities of the space to be mea- 
sured are indistinctly defined. This is especially true of typhoid 
fever. The access of the disease is often gradual, and convales- 
cence establishes itself, by slow and almost imperceptible degrees. 
There is often, also, here another source of difficulty, arising from 
the state of mind, in which the patient is found. His impressions 
are cloudy; his recollections are indistinct, and he will often date 
the commencement of his illness several days later than it really 
occurred. Bearing these circumstances in mind, I proceed to 
state, as nearly as has been ascertained, the usual duration of the 
disease. 

Dr. Jackson, following the example of Louis in regard to pneu- 
monia, fixes the commencement of convalescence, at the time 
when the patient is able to take a moderate quantity of solid food, 
the febrile symptoms having subsided, for at least two or three 
days previous to this period. In two hundred and fifty-five cases, 
at the Massachusetts General Hospital, between the years 1824 
and 1835, inclusive, the average duration of the disease w^as 
twenty-two days. It was a little less than this, in those under 
twenty-one years old, and a little more, in those over. The dura- 
tion varied in difTerent years, from eighteen to twenty-six days. 
Dr. Jackson thinks, that convalescence commences, in a few rare 
instances, as early as the seventh day.^ Of one hundred and 
eighty-six cases, at the same hospital, between October 1st, 1833, 
and October 1st, 1839, the average duration w^as ^/«r^y-m??.e days. ^ 

' Dr. Jackson's Report on Typhoid Fever, pp. 108, 109, 110, 111. 
2 Hale on the Typhoid Fever of New England, p. 241. 



110 TFPHOID FETER. 

Of sixtv-T:_i" TiT? :i:_i:: ::::ig" fe-TOTE ; / . :i t; _ ^ , lz 

ssfs :,. -:5 :. -;;;-: :::.:-r ::: -i. :--:,;:-. -:-;■•'=-_ 

eft 5 £ L - li -^-rv-fifai.* 

undt: 'Iz :';.::-T :.:.-! -^r-^ :"::- i:i irzizifi iTiiri: : -ii -L-: it 
Tartr T :: 7 5 r ::! ":-t :r irtt-^ Of Ae fiwrty-six fets. 55 
ana- ^ It .: :: 1: ".Sjten teiminated betwfrL :ii 

pjgl--'- : :. J 7 5 : 5 5 7:^een the SEXteenth and r^en- 

tietL: "ri. \ 7 ~77:- 7 —5: 71 :.£ tiiiiiietli ; and nine, after 
tins r 7. : : - - :: 5 7 5 ; 5 ; :: : ii-r "i. Richmond, Beikshire 

Coozi:;, :::555i: 15 : 5 7 771 .^ -s:, iSiO, and Febraaiy, 
1841, the areragt 151:5-^5:: was nearly forfj-one days. It ought 
to be stated, howe- i : 1 e inration in three d these cases is 

stated, lespecfiTelj. .: 5:7 _:ndred,one hondred and serenty- 
three, and two hundred days. This ^treme pmlongafion was 
probably caused by some accidental complication. Forfy-six 
cases occoixed in the same *o^;ni, between Angnst, 1841, and 
May, 1842; the average dt : : 'Jiese, being a little more tt ar. 

fL:r^7-'5:7 7 :'ays. Modes:: railier than the twelfili :: 

:i:r: 7 7 5 t - in no case : : 7 7 -as the duration less tt a r. 



AETICLE n. 



COMPLICATIONS. 



on the whole, pre : 7 _ 

7^7-fty, the patienrf ,7- _:_iaixv 

bree weeks; •::. 5:7: tiie first 

1 Teiy ht\ 7 :: : ^- e, nntii 

7 .5 7 57 !? not iLsuduiv marked 

7:17: : - : : able or nn&Torable, 

>• : s it maiked by 

. " s :..::.. :- .. __ ^■l_„„ ^-„^*.^^ - 

:i vjuLnuica li . ._-7"r Sr^:r^-- > 



COMPLICATIONS.— PERITONITIS. HI 

periods, dating from the distinct and formal onset of the disease. 
This is arbitrary, but very well as a matter of convenience.^ 

Typhoid fever is occasionally, but not often, complicated with 
other diseases. Nathan Smith says, that he has often seen it fol- 
low dysentery, and that he has known it to co-exist with epidemic 
catarrh. Chomel gives a case in which it was complicated, at 
its commencement, with acute pneumonia. Erysipelas some- 
times occurs in the course of the disease, and this more frequently 
during some seasons than others. During the winter of 1846-7, 
in Lexington, Kentucky, there were several cases, attended with 
a bright erysipelatous redness of the nose ; and the same redness 
was seen in some persons not suffering w^ith the fever. 

ARTICLE in. 

PERITONITIS. 

There is one other accident, liable to occur in the progress of 
typhoid fever, of which it is necessary to speak more particularly. 
I mean acute inflammation of the peritoneum, occasioned by the 
discharge into its cavity, of the contents of the small intestine, 
through a perforation. The lesion itself has already been de- 
scribed. It was first fully investigated, its nature and causes 
pointed out, and its diagnosis established, by Louis. ^ In a ma- 
jority of instances, it takes place in cases of moderate severity, or 
in those which have been described as latent, and at a late period 
of the disease. Its occurrence is marked by the sudden super- 
vention of acute pain in the abdomen. This pain comes on, all 
at once, with no premonitory symptoms, with nothing in the con- 
dition of the patient to account for it, and the suffering which it 
occasions is excessive. The access of the pain is frequently ac- 
companied by chills, the abdomen becomes rapidly and acutely 
tender on pressure, and, if it was not so before, hard and tym- 
panitic. The pulse is quick and compressed. An instantaneous 
change takes place in the physiognomy of the patient. The 
countenance is expressive of intense suffering; the features are 
pinched and cadaverous ; and the face is covered with a profuse 
sweat. There is a constant and urgent desire for cold drinks. 

' Le9ons de Clinique Medicale. Chomel, p. 6. 

2 Memoires sur diverses Maladies, Paris, 1826, p. 156, et seq. 



112 TYPHOID FEVER. 

Nausea and vomiting are present, soon after the inflammation has 
commenced ; the matter ejected from the stomach is of a grass 
green color, and it continues to be thrown up to the last moment 
of life. Notwithstanding the constancy and the intensity of the 
distress, the patient preserves the same position, lying upon his 
back, and dreading every moment that may add to the pain and ten- 
derness of the abdomen. Such, in most cases, is the formidable 
array of svmptoms, which indicate the occurrence and mark the 
progress of this fatal complication. Occasionally they are more 
obscure ; and this peritoneal inflammation, like the fever itself, 
is, to a certain extent, latent. It is exceedingly rare, however, 
that there can be any difficulty in ascertaining its existence. 
Death usually takes place, in from one to three days after the oc- 
currence of the perforation. 

ARTICLE IV. 

RELAPSES. 

It seems to be very well settled, that true relapses, as they are 
called, not unfrequently occur in this disease. Dr. Jackson re- 
marks, that an error in diet and regimen is often followed b}' a 
new train of symptoms, after convalescence from typhoid fever; 
and that they appear to be such symptoms as belong to the fever, 
although not always so strongly characteristic, as to leave no 
doubt on the subject. He cites a case in which, during the re- 
lapse, there was an eruption of the rose spots. Dr. Stewart reports 
two cases, wherein amongst many other of the more peculiar 
symptoms of the disease, the relapses were also attended by a re- 
appearance of the typhoid eruption.^ Indeed, there are, probably, 
few physicians, extensively conversant with tj-phoid fever, who 
have not, more than once, seen convalescence fatally interrupted 
by a sudden return or an aggravation of many of the most cha- 
racteristic symptoms of the disease, the delirium, the diarrhoea, 
the subsultus, the tympanites, and so on; constituting, not the 
supervention of a new, accidental affection, but a genuine relapse. 

' Edin. Med. and Surg. Journ., Oct. 1840. 



SEQUELiE. 113 

ARTICLE V. 

SEQUELS. 

The most serious sequel of typhoid fever is tubercular con- 
sumption. This has been particularly noticed by Dr. Gerhard, of 
Philadelphia. In patients of a strumous or cachectic habit, it 
not unfrequently follows immediately, or very soon, upon the 
fever, and usually runs on with great rapidity to a fatal termina- 
tion. 

Dr. Jackson notices a painful state of one or both legs, coming 
on after convalescence, attended with more or less lameness in 
motion, causing much anxiety, and continuing from a few days to 
several weeks. There were eight cases of this kind in the hospital. 
Entire recovery took place in all. Dr. Jackson also mentions five 
cases, in which, at a late period of the disease, there was swell- 
ing of one leg from well marked phlebitis.-^ Nathan Smith alludes 
to the same occurrence.^ I have seen this sw^elled leg in only 
one instance. Barthez and Rilliet have met with several cases of 
anasarca during convalescence. 

^ Dr. Jackson's Report on Typhoid Fever, p. 133, 
2 Smith's Med. and Surg. Memoirs, p. 67. 



114 



CHAPTER VII. 

MORTALITY A_\D PKOGNOSIS. 

Typeoid fever must be considered, on the whole, as a grare 
disease. I have already had occasion, in treating of its different 
forms and yarieties, to give some instances of its rate of mortality, 
in different seasons and places.^ — This depends so much upon 
the character of the disease, in any particular locality, and during 
anv given period, that it is not an easy matter to arrive at any 
positive and accurate general, or average, result. The prognosis, 
as well as the diagnosis, of this disease, is a complex problem, 
into the solution of which, in each individual case, there enters a 
great number of phenomena. Instead of going any further into 
the question of the average and varying mortality of the disease, 
I will now endeavor to appreciate, as far as this can be done, the 
value of the several elements, which go to make up our prognosis. 
In doing this, I shall first briefly pass in review, and as nearly as 
this can be done, in the same order in which they have already 
been described, the several symptoms of the disease ; and I will 
then speak of some other considerations, connected with its degree 
of severity, and consequent danger. 

The mode of invasion would seem to have no small degree of 
influence upon the subsequent character of the disease. This has 
been particularly shown by the investigations of Chomel. In his 
wards at the Hotel Dieu, of sevent}"-three cases, in which the 
access was sudden, only twenty-six were fatal ; while there were 
twenty deaths in only thirty-nine cases, in which the access was 
gradual. 

The strictly ye5ri/e symptoms are not, in themselves, of much 
value in prognosis. A pulse more rapid than 120 or 130 in the 
minute, constitutes an unfavorable sign; especially if associated 
with any other grave symptoms. Still, it frequently happens, 
that cases recover, in which this rapidity of the pulse has been 

* See page 106, 107. 



MORTALITY AND PROGNOSIS. 115 

present, for a considerable period of time. In two hundred and 
ninety cases, cited by Dr. Jackson in his Report, the average fre- 
quency of the pulse in those which recovered was, in round num- 
bers, about twenty in a minute less, than in those which ended 
fatally. It was also from fifteen to twenty in the minute more 
frequent in females, than in males. Dr. Jackson remarks, in his 
report, that he has not found chills, at an advanced or late period 
of the disease, to have been followed by very grave consequences, 
though he had previously had a different impression. Of twenty- 
nine cases, in which these chills were noted, only two terminated 
fatally. Louis says, that they indicate the commencement of 
some secondary lesion. 

The noisy, hissing, and irregular respiration, to which I have 
applied the term cerebral^ is a very dangerous indication; and, as 
is said by Chomel, when connected wdth other grave symptoms, 
renders the case almost utterly hopeless. 

Delirium, especially if it occurs at an early period, and is of a 
wild and violent kind, is of very bad augury. Many patients, in 
whom it comes on late, and in whom it is of a mild, muttering 
character, recover. Of one hundred and eight cases, mentioned 
in Dr. Jackson's Report, this symptom was present, in two cases 
in seven of those w'hich terminated favorably ; and in four cases 
in five of those which terminated unfavorably. Transient and 
slight delirium, occurring during the night, or immediately after 
waking from sleep, and easily dissipated by attracting the atten- 
tion of the patient, cannot, in itself, be regarded as a very serious 
symptom. There is a peculiar perversion of the mind, occasion- 
ally seen, the presence of which indicates great and imminent 
danger. This consists in a feeling, on the part of the patient, 
that he is not much sick; when he says, even in the midst of the 
gravest symptoms, that he feels, and that he is, very w^ell. Louis 
says, that he has never known this state of the mind in a patient 
who recovered. 

Somnolence and coma are unfavorable symptoms, in proportion 
to their degree, and to the early period of their access. If they 
are present at or near the beginning of the disease, and are at all 
strongly marked, they are very constantly followed by a fatal ter- 
mination. Moderate sleepiness or stupor, from which the patient 
is pretty readily roused, is common in cases of moderate severity ; 
but prolonged and profound coma indicates a very formidable 



116 TYPHOID FEVER. 

grade of the disease. Watchfulness, restlessness, and agitation 
are, also, unfavorable symptoms. Deafness and epistaxis, are, 
neither of them, of any considerable importance as prognostic 
signs. They occur with nearly the same frequency, and to nearly 
the same extent, in grave and in mild cases. The same thing is 
true of dizziness, and noises in the ears. 

Spasmodic contractions of the muscles, either of the face, or of 
the arms and hands, constituting suhsultus tendinum, or of other 
parts of the body, are of grave omen. They occur very much 
more frequently, in cases which are fatal, than in those which 
recover. According to Dr. Jackson's Report, they were noted, at 
the Mass. Gen. Hospital, in one case in a little less than four, of 
those which terminated unfavorably; and in one case in ten, of 
those which terminated favorably. If these contractions are 
general and strongly marked, constituting a kind of epileptiform 
agitation of the whole body, or of all the limbs, the case is almost 
invariably fatal. Such is also the case, w^here there is permanent 
rigidity of one of the limbs. Louis has never seen a case of this 
sort recover ; and he says, that he knows of no one amongst his 
cotemporaries, except Chomel, who has. Barthez and Rilliet 
saw five cases of rigidity of the muscles of the trunk, in children, 
all of which terminated fatally; and two cases of convulsions, 
which ended also in death. Dr. Jackson reports six cases, in 
which this symptom occurred, only one of which ended in re- 
covery. Early and extreme prostration of strength is likely to be 
followed by a grave and dangerous form of the disease. 

The expression of the countenance may sometimes be of ser- 
vice in our prognosis. It is hardly necessary to say, that the 
pinched, cadaverous, Hippocratic face generally indicates speedi- 
ly approaching dissolution. On the other hand, the reappearance 
of intelligent expression on the features from which it had long 
been banished ; the re-illumination of the dull and listless eye ; 
the recognition by the patient of his friends and attendants; ac- 
companied by the manifestation of interest in his own situation 
and safety, and in surrounding circumstances, are, even in the 
midst of many grave symptoms, cheering indications of a change 
that will end in recovery. 

The appearance of the tongue is of less importance as a prog- 
nostic sign than has generally been supposed. It is worth some- 
thing, but in itself, not a great deal. In Dr. Jackson's cases, the 



MORTALITY AND PROGNOSIS. 117 

rate of mortality, Avith a dry tongue, was 1 in 4.71 ; with a denuded 
tongue, 1 in 8; with a dark tongue, 1 in 3.23.^ A very dry, 
cracked, red or blackish tongue is more unfavorable, certainly, 
than one that is moist, with a thin, brownish or yellowish coat; 
but the former appearances are not unfrequently present in cases 
which recover, and unless accompanied with other grave symp- 
toms are not much to be regarded. 

Difficulty of swallowing, especially if great, is an unfavorable 
sign. 

Meteorism, or tympanitic distention of the abdomen, constitutes 
an unfavorable symptom, only when it is strongly marked.^ 

Diarrhoea, if urgent and continued, is a grave symptom. It is 
much more constantly present in severe and fatal cases, than in 
mild ones, although patients often recover who have suffered 
greatly and for a long time with it. Nathan Smith says, — "The 
danger of the disease is in proportion to the violence of the diar- 
rhoea ; when the patient has not more than four or five liquid 
stools in the twenty-four hours, it is not alarming; as it does not 
seem to weaken him much; but if they exceed that number, 
serious consequences may be apprehended. I have never lost a 
patient, whose bowels continued constipated through the whole 
course of the disease, and have never known a fatal case of typhus, 
unattended by diarrhoea." 

Involuntary discharges from the bowels rarely take place, ex- 
cept in the late stage of very severe cases. Of course, they 
point towards an unfavorable termination, although they are far 
from indicating with any certainty such a result. Of thirty cases, 
in which this symptom was present, mentioned by Chomel, thir- 
teen ended in death. Of ten cases, cited by Dr. Jackson, only 
four recovered. 

Hemorrhage from the bowels is a grave symptom, though far 
from an invariably fatal one. Of seven cases, cited by Chomel, 
all but one terminated unfavorably. The experience of others, 
however, is less discouraging. Of seven cases, mentioned by 
Louis, three were fatal ; and of thirty-one cases, occurring in the 
Massachusetts General Hospital, eleven only terminated unfavor- 
ably. I have certainly seen as many instances of recovery, as of 
death, in patients who have suffered from this accident. I do not 

' Report, &c., p. 115. ' Louis on Typhoid Fever, vol. ii. p. 341, 2d ed. 



118 TYPHOID FEVER. 

know that the quality of the intestinal discharges, in any other 
respect, has any constant relation to the danger of the disease. 

Retention of urine is an unfavorable symptom. Of six cases, 
in which it was present, at the Massachusetts General Hospital, 
three were fatal. 

Erysipelas occurs oftenest in the course of severe and alarming 
cases. It not only indicates a grave form of the disease, but it 
adds, also, to its danger. The rose spots occur with like frequency 
in all grades of the disease, and are destitute, of course, of any 
prognostic value. The same remarks may be made of eschars 
upon the sacrum, as have just been made in regard to erysipelas. 

Before leaving this consideration of the several symptoms of 
typhoid fever, in their relation to prognosis, it is important to no- 
tice one other circumstance, of occasional occurrence, bearing 
upon this subject. It sometimes happens, that a very wtII marked 
amelioration of all the symptoms takes place, somewhere, usually, 
between the tenth and twentieth days of the disease ; constituting, 
indeed, an apparent convalescence; and that this amendment is 
soon after followed by the return, in an aggravated form, of the 
symptoms which had subsided, or diminished in severity. This 
species of relapse is almost invariably followed by death. This 
circumstance is particularly noticed by Chomel, and the truth of 
his remarks is corroborated by Louis. 

Besides the foregoing, there are some other circumstances, 
which affect in a general way, the question of prognosis in typhoid 
fever. The principal of these are age, season, and acclimation. 

Speaking now of adult patients, that is of those over fifteen 
years old, it seems very certain, that the danger to be apprehended 
from this disease, is somewhat in proportion to their increased age. 
The mortality is smaller between the ages of fifteen and twenty, 
than it is between the ages of twenty and twenty-five ; or than it 
is at any subsequent period of like duration. The mortality at 
the Hotel Dieu, in Chomel's wards, was one in five, between the 
ages of fifteen and twenty ; one in four, between the ages of 
twenty and twenty-five ; and one in two, over the age of thirty- 
five. Louis and Chomel agree in saying, that they have rarely 
found cases to terminate fatally, where the patients were between 
the ages of fifteen and seventeen years. At the Massachusetts 
General Hospital, Dr. Jackson found the average age in the fatal 
cases, to be a little more than two years greater, than in the cases 



MORTALITY AND PROGNOSIS. 119 

not fatal. He found, also, upon a further analysis, that in those 
patients ^vhose ages were thirty-five years or more, the mortality 
was one in four ; while in those whose ages were twenty years 
or less, it was only one in nearly eleven. The prognosis is said 
to be more favorable amongst children, than amongst adults; but 
of Barthez and Rilliet's one hundred and eleven cases, twenty- 
nine terminated fatally. 

It would appear, from the observations of Chomel, that typhoid 
fever is more grave and fatal in the cold, than it is in the warm 
season. At the Hotel Dieu, in 1832, the mortality was one in 
three, during the winter, and one in six, during the summer ; in 

1834, it was one in two and a half, during the winter, and one in 
seven, during the summer; and in 1835, the average proportions 
were the same as in 1832. An exception to this general result 
occurred in 1831, when the proportion of deaths was one in four 
during the Avinter, and one in three during the summer. The 
number of cases, how^ever, in the hospital, this year was small. 
Chomel appears to have no doubt as to the influence of season 
upon the severity and mortality of the disease.^ I do not know 
how far his conclusions are sustained by the observations of others. 
The most fatal form of the disease, that has ever been witnessed 
in the city of Lowell, prevailed during a winter of extreme se- 
verity. In the Massachusetts General Hospital, from 1822 to 

1835, the rate of mortality during the cold months was 1 in 6.39; 
while in the warm months it was only 1 in 8.21.^ 

Of one hundred and eighty-three cases given by Forget, forty- 
three terminated fatally. The rate of mortality varied with the 
seasons in the following manner: in the autumn, it was one in 
4t%; in the winter, one in 3t\; in the spring, one in 3rT; and 
in the summer, one in 6|^.^ , • 

It seems, also, and this principally from the results obtained by 
Chomel, at the Hotel Dieu, that the length of time, during which 
patients have resided wherever they suffer from the disease, has 
some influence upon its mortality. Between the first of Novem- 
ber, 1834, and the first of August 1835, there w^ere ninety cases 
of typhoid fever in ChomePs wards at the Hotel Dieu. Amongst 
those patients, who had resided in Paris less than one year, the 

' La Lancette Frangaise. August, 1835. 

2 Dr. Jackson's Report, p. 107. 

3 Traite de lEnterite Folliculeuse. Par C. P. Forget, p. 409. 



120 TYPHOID FEVER. 

mortality was one in three; amongst those, who had resided in 
Paris between one and two years, the mortality was one in five ; 
and of fifteen, who had resided in Paris more than two years, only 
one died. There is reason to think, that this result is not acci- 
dental, since the same differences, though to a less striking extent, 
were noticed during the three pre\-ious years, and since they are 
also in keeping with the observations of Louis. ^ Chomel has 
suggested that a certain degree of general debility, either consti- 
tutional, or the result of previous disease, may act favorably upon 
the severity and the termination of typhoid fever. Forget says 
he has often been struck with the rapidity with which the disease 
has run on to a fatal termination, in cases of young persons with 
rich, vigorous, and fine constitutions, so that it was not without a 
secret terror that he saw these patients enter the hospital.^ 

Whether typhoid fever is any way influenced in its severity by 
race^ I am unable to say. During the year 1846, Dr. Sutton, of 
Georgetown, Ky., saw forty-three cases of the disease. Thirty of 
these were amongst whites, and eight of them were fatal, — 1 in 4 ; 
thirteen were amongst negroes, two of which were fatal, — 1 in 6J. 
These numbers are of course too small to be in themselves of much 
value. 

There is no evidence, that the supposed, occasional, exciting 
causes of typhoid fever, such as scanty and poor diet, depressing 
emotions, fatigue and excesses, have any effect upon the severity 
and fatality of the disease. 

It must be obvious enoug^h, from all the foreo^oino^ considera- 
tions, that the prognosis, in any given individual case of typhoid 
fever, can very rarely, if ever, be absolute, and positive. Patients 
sometimes recover from the most desperate condition; they are 
liable to the most dangerous and fatal accidents, in the mildest 
cases. But, notwithstanding these contingencies, we may, in a 
great majority of instances, by a careful study of all the circum- 
stances which can influence the result, arrive at a good degree of 
approximative certainty in our prognosis. In a moderate propor- 
tion of cases, the scales of life and death may hang, for many 
days, so far as we are able to see, in almost exact equilibrium ; 
and no foresight or sagacity can predict, with any degree of con- 
fidence, which of the two will finally preponderate. Favorable 

' La Lancette Fran9aise. August, 1835. 
2 Traite de TEnterite Folliculeuse, p. 404. 



MORTALITY AND PROGNOSIS. 121 

and unfavorable symptoms will be so combined, and so attem- 
pered, as to baffle all the efforts of ^visdom and experience to 
calculate their issues. Hope and fear are constant and equal 
watchers by the bed-side of the sick. In all the rest, however, 
the general character of the symptoms will be, one way or the 
other, so marked and so decided, as to enable us to judge, with a 
reasonable degree of certainty, as to the result. If during the 
first fortnight, the pulse is not more than one hundred or one 
hundred and ten in the minute; if there is only moderate drowsi- 
ness; if there is no delirium, or even if this, though present, has 
not appeared at an early period of the disease, and is easily dis- 
sipated, or mild in its character; if there is no twitching of the 
tendons; if the patient gets some comfortable sleep; if the diar- 
rhoea and tympanitic state of the abdomen are moderate in degree ; 
the chances of recovery are vastly in favor of the patient. • Bear- 
ing in mind the liability, which always exists, to a sudden aggra- 
vation of the symptoms, to the supervention of some secondary 
complication, and to the occurrence of intestinal perforation, and 
the qualification necessarily accompanying this liability, we may, 
in such cases, with great confidence, anticipate a favorable result. 
On the other hand, if the pulse is more than one hundred and ten, 
or one hundred and twenty in the minute ; if there is great stupor, 
or coma; if the delirium comes on early, and is wild and furious; 
if there are spasmodic contractions of the muscles, picking at the 
bed-clothes, and great prostration of strength; if there is restless- 
ness, or agitation; if the diarrhoea is urgent, and continued; if the 
distention of the abdomen is extreme ; if the odor from the patient 
is musty, and cadaverous; if the features are pinched, and Hip- 
pocratic ; especially, if there are general epileptiform convulsions, 
or permanent rigidity of one of the limbs ; or that peculiar perver- 
sion of the intellect, which leads the patient, in the midst of this 
terrible combination of threatening circumstances, to suppose and 
to declare himself free from suffering and danger; if these symp- 
toms, or any considerable number of them, are present, we can 
have very little ground to look for any but a fatal termination ; 
and this termination we may, with great confidence, predict. 



122 



CHAPTER YIIL 

Iff is (DielIj suce 1^ piil)]ica1ion of tte work of Louis, by the aid 

of Ms and of subsequent researciies, tL.at typboid fexer bas been 
distingiiisbed, -with any considerable degree of constancy, and 
ceilainty, from other more or less analogous forms of disease. 
And even now, there are few problems in diagnosis, more com- 
plex than this ; although, by the application of the requisite know- 
! 7 r - iiid cazre, its solution is almost always attainable. The 
r;T_T:. 5. — h::h f-"fr into the composition of this problem, are 
Z-ii; 11 _ " i: :i;. There is no one symptom, there are no two 
<ar lirae s^wBplssm&, -whk^ m ihem^elTes, are ch.ajacteristic of the 
Tlios is no ©me symptom, there are no two or three 
msnally occiiiiing in the disease, which may not be 
ahseffil, dmia^ ite entire progress. Our diagnosis can nerer be 
fiimided fcereg as it is in many other instances, on a few, positive, 
pliyisiical a^ns. It must always be rational, not absolute. The 
•cwidoM^ upon which our verdict is to be rendered, is whoDy cir- 
OHTtStimtial. Notwithstanding' all this, and although cases some- 
times occirr, so enveloped in obscnrity, as to baffle the skill of the 
:i : r' : ireful and experienced observers; it is still true, that there 
ijc ic^ general diseases, the diagnosis of which is so well esta- 
biidhed, and so certain, as that of typhoid fever. ^ 

Peiiaps, in the present state of science, a single qualification 
cwaght to be affixed to this last remark. The whole question of 
the diagnosis of the several individual diseases, constituting the 

--- - :'~~^t~^ of my Itook graxelr cites this admission, of the occaaonal 

•5iffi:\ ;'3^ibility, of making an absolnte and positixe diagnosis, as sxifficient 

prou:. _; ; ^.:e is no specific difference between the typhvs and the typhoid forms 
Cff ijantraned fever, — ?& thongh there could "be no snch indiTidoal diseases as CEinceT 
(df ihe stomadh, or softening of the brain, because "we are not always able to m.ai:e 
, cttit with entire cejiajpiy during life] 



DIAGNOSIS. 123 

family of idiopathic, or essential fevers, has been undergoing, ever 
since the publication of the work of Louis, a more rigorous and 
philosophical scrutiny, than it had been subjected to before. Much 
of the chaotic confusion, in which this question had always been 
involved, has been cleared up. Diseases, which had occupied 
distinct, and perhaps widely separated, places in the nosologies, 
have been shown to be identical ; and diseases, on the other hand, 
have been shown to be widely different in their character, which 
had been regarded as identical. Some of these questions of differ- 
ence and identity are still unsettled ; they are matters not yet finally 
and definitively disposed of; not yet ranked amongst the esta- 
blished principles of medical science. One of the most important 
and interesting of these, and this constitutes the qualification 
which I wished to make, is that of the differences between the dis- 
ease now under consideration, and the true typhus fever. By 
many pathologists, the two diseases are considered to be essentially 
alike, identical. Until within a few years, this was the general 
opinion ; and even now, it is almost universally entertained by the 
British physicians, who have enjoyed the most extensive oppor- 
tunities for studying and comparing the two diseases, or the two 
forms of disease, as the case may be. By other pathologists, 
these diseases are considered to be essentially and fundamentally 
unlike each other; — unlike in their nature ; in their symptoms; in 
their pathology; and in the mode of management which they re- 
quire. I believe this last opinion to be the true one ; but it cannot 
be satisfactorily discussed, until both diseases have been described. 
For this reason, I shall omit, in what I have now to say upon the 
diagnosis of typhoid fever, the consideration of the differences 
between it and the true British typhus. 

Setting aside then, as I do for the present, the true typhus fever, 
there is no disease, more readily and positively recognized, than a 
case of well marked typhoid fever, of extreme, or even of average, 
severity; when observed from its commencement, and followed 
through its entire course. It is hardly possible to confound it with 
any other affection. There is no other, in any considerable de- 
gree, resembling it. Chills, more or less severe, repeated or not ; 
accompanied with, or immediately followed by, headache, and 
pains in the back and limbs ; these pains subsiding and disappear- 
ing in the course of a few days ; thirst; heat of the skin; accelera- 
tion of the pulse, with an evening exacerbation ; entire loss of 



124 TYPHOID FEVER. 

appetite; great muscular debility; dullness and confusion of the 
intellect, passing gradually into delirium ; restlessness; vigilance, 
or somnolence ; twitching of the tendons, or picking at imaginary 
objects; occasional epistaxis; ringing, or buzzing, in the ears; 
the appearance of a scattered, rose-colored, eruption, principally 
upon the skin of the chest, or abdomen, during the second week ; a 
dry, glutinous, cracked, red, brown, or blackish tongue, protruded 
with difficulty, and trembling ; dark, thick, sordes upon the teeth ; 
diarrhoea, the stools thin, watery, and dark, or yellowish, sometimes 
consistingof blood; tympanitic distention of the abdomen ; dullness 
on percussion over the spleen, and gurgling upon pressure upon 
the right iliac region ; with a dry sibilant or sonorous rhonchus 
over the chest : these symptoms, coming on without any obvious 
cause, occurring usually in a person under forty years of age, and 
referable to no local disease ; more or less regularly and succes- 
sively developed; increasing in severity, and terminating in death, 
at an indefinite period after the eighth day ; or gradually subsid- 
ing, and disappearing, one after another, and giving way to con- 
valescence, at an indefinite period after the fifteenth or twentieth 
day; mark, most clearly and unequivocally, a disease wholly un~ 
like any other. These symptoms are sometimes, during the pro- 
gress of the disease, and in various degrees of relative severity, 
all of them present ; and in these cases, at any rate, there is no 
possibility of mistaJdng typhoid fever for any other disease. The 
diagnosis, independent of the evidence to be derived from the 
lesions found after death, in the fatal cases, is easily and certainly 
made. 

In other instances, many of the foregoing, and, amongst them, 
some of the most characteristic symptoms, may be wanting; and 
still the diagnosis may remain in no way difficult, or doubtful. 
Some of the most serious disturbances of the nervous system may 
be absent. There maybe no morbid watchfulness, or drowsiness; 
no aberration of the mind ; no twitching of the tendons ; but if 
the other symptoms, above enumerated, are present, there can be 
no uncertainty as to the character of the disease. Again, it may 
happen, that the abdominal symptoms, — the diarrhcea, and tym- 
panitic distention, may be wanting, without throwing any doubt 
upon the diagnosis. We may go further than this. Let us sup- 
pose that a person, between the ages of fifteen and thirty, is at- 
tacked, without any appreciable cause, by the febrile symptoms, 



DIAGNOSIS. 125 

already repeatedly described ; attended or followed by loss of ap- 
petite ; sufficient prostration of muscular strength to confine the 
patient to his bed ; occasional epistaxis ; slight dizziness, or ring- 
ing in the ears, at least on assuming the upright position ; and 
that these symptoms cannot be referred to any local disturbance, 
and persist for as many as twelve or fifteen days, with but little 
change, and not much influenced by medicine; even under these 
circumsfances there can be but little question as to the disease. In 
most cases, there will be found at least as many elements of diag- 
nosis, as in that just supposed ; in very many, there \\i\\ be more. 
Almost always, the lenticular eruption will be discovered, if it is 
timely and carefully sought for ; if there is no diarrhoea, there 
may be slight distention of the abdomen, with gurgling on pres- 
sure over the region of the cecum ; or there may be deafness, or 
sluggishness of the mind, or transient and wandering delirium, 
or, finally, some one or two of the numerous symptoms, more or 
less characteristic of the disease. 

I do not mean to say by this, that typhoid fever can always be 
distinguished, with certainty, from other diseases, even when it is 
watched during its whole course, and by the best observers. Un- 
questionably, the disease is sometimes so nearly latent, or so 
poorly defined, as to be overlooked or mistaken; but with ordi- 
nary knowledge of its character, its symptoms, and their march, 
and with careful examination, this will very rarely be the case. 

It may happen, not unfrequently, that the disease cannot be posi- 
tively made out, during the first few days after its access. The 
febrile symptoms, the chills, heat, thirst, accelerated circulation, 
with the pain in the head and limbs, are amongst the most pro- 
minent at this period, and they are those least characteristic of 
this disease. They are, indeed, common to the early period of 
this and of many other febrile aflfections, and of the local phleg- 
masise; so that, until the subsequent and more distinctive and 
pecuKar symptoms of the disease, w^hatever this may be, show 
themselves, it may not be possible to establish our diagnosis. In 
the same way, it may happen, that the disease is not seen till it 
has reached its late stage. Many of its most important diagnos- 
tic characters may have disappeared, and no satisfactory history 
of its anterior progress can be obtained. Under such circum- 
stances, it may sometimes be confounded with other affections; 
with dysentery in its late stages ; with some diseases of the brain ; 



126 TYPHOID FEVER. 

and with local inflammations, which are strongly marked, espe- 
cially near to their fatal termination, with what may be called the 
typhoid element in pathology. Louis once mistook a case of cen- 
tral softening of the brain, occurring in a boy, for typhoid fever. 
Erysipelas is often attended with many of the symptoms of this 
disease; delirium, drow^siness, or stupor; red, or brown and dry 
tongue, fuliginous teeth and gums, tympanites, and great prostra- 
tioir of strength, so that were it not for the presence, from the com- 
mencement, of the cutaneous inflammation, it might sometimes be 
confounded with typhoid fever. 

The diagnosis of typhoid fever in children is sometimes attend- 
ed with considerable difficulty. The diseases, with which it is 
most likely to be confounded, are gastro -intestinal irritation, ac- 
companied by fever, and meningitis. The following points of 
difference between it, and these diseases, are enumerated by Bar- 
thez and Rilliet. Typhoid fever may be distinguished from gas- 
tritis, by the presence, in the former, of a greater degree of de- 
bility, than usually attends the latter ; by a moderate agitation, or 
delirium, during the night ; by diarrhoea, and gurgling on pres- 
sure, over the ileo-cecal region ; by dullness, on percussion, over 
the region of the spleen; by the rose spots, and sudamina, at least 
in a large majority of cases ; by more intense and prolonged febrile 
excitement; and by the physical signs of bronchitis. From in- 
testinal, or gastro-intestinal, irritation, it may be distinguished by 
the same signs, excepting the diarrhoea. 

The disease in children, with which typhoid fever is more likely 
to be confounded, than with any other, is meningitis. A careful 
attention to all the phenomena of the two diseases will, however, 
generally enable us to distinguish between them. In many cases, 
the pulse is more rapid, at the commencement of the disease, in 
typhoid fever, than it is in meningitis, although this difference is 
not sufficiently constant to be much relied upon. Spontaneous 
nausea and vomiting are more common in the latter, than in the 
former; and the headache is generally more severe. There is a 
very constant and striking difference in the state of the bowels; in 
typhoid fever, there is diarrhoea; in meningitis, there is constipa- 
tion. The tongue is more frequently dry, brown, and cracked, 
and the lips and gums covered with sordes, in the former, than in 
the latter. The early stage of meningitis is more frequently at- 
tended by extreme agitation, and delirium, than that of typhoid 



DIAGNOSIS. 127 

fever; and, finally, the latter is more frequently accompanied by 
slio-ht cough, and a dry, sibilant rhonchus, than the former. I 
may add, that ^vhile general convulsions are common during the 
middle and latter stages of meningitis, they seem to be very rare 
in typhoid fever, since Barthez and Rilliet met with them only 
twice in one hundred and eleven cases. 

Typhoid fever, like all other continued affections, is sometimes 
more or less mixed up w^ith and influenced by the pathological 
element of periodicity. This will happen most frequently and 
will be most strongly marked in malarious regions, and during 
the prevalence of remittent and intermittent fever. Dr. Wooten 
of Lowndesboro', Alabama, in a letter to me, says, — "I may re- 
mark that I have often seen typhoid fever complicated with regular 
remittence, — that is, typhoid fever and remittent fever existing 
together; and I have cured the paroxysmal exacerbations, whilst 
the disease essential to typhoid fever continued ; and I have fre- 
quently found it necessary to do this, before the more formidable 
disease could be influenced by remedies. I have seen such cases 
in the practice of physicians, w^ho supposed them to be remittent 
or bilious fevers, in w-hich the bowels had become diseased as a 
consequence of the fever. I think this is a very common error. 
The malarial influence frequently so preponderates in the symp- 
toms of inflammatory diseases in our latitude, as to obscure the 
real disease for many days; and in such cases it is easy to look 
upon such influence as the cause of the structural lesion, whilst, 
in fact, the latter has acted as the exciting cause to the manifesta- 
tions of the former." Dr. J. G. Core, of Williamson county, 
Tennessee, also in a letter to me, speaks of this same blending, 
occasionally, of the remittent element with typhoid fever. "Re- 
mittent fever," — he says further, — "will certainly run into a 
typhoid type, unless it is checked early before it becomes com- 
plicated; but that is far from being a case of true typhoid fever." 
I have said nothing, thus far, of the lesion of the elliptical 
plates, as an element in the diagnosis of the fatal cases. It has 
already been remarked, that this lesion is characteristic of this 
disease ; that it is invariably found in the fatal cases of typhoid 
fever ; and that it is not found in fatal cases of any other acute 
disease. If this is absolutely true, without exception and without 
qualification, then the presence or the absence of the lesion ought 
to be final and decisive, in regard to the diagnosis. Let us see 



]^28 TYPHOID FEVER. 

what the evidence is upon this matter. I have already spoken 
of one case, which was regarded by Louis, as typhoid fever dur- 
ing life. A post-mortem examination showed that the elliptical 
plates and mesenteric glands were healthy, and that death was 
the result of softening of the central portions of the brain. This, 
then, was, manifestly, not a case of typhoid fever. Not only were 
the usual lesions of this disease wholly wanting; but all the symp- 
toms, and the fatal result, were sufficiently accounted for by the 
cerebral lesion. This was a case of disease of the brain, simulat- 
ing, to a certain extent, typhoid fever. And even here, it is but 
justice to say, that Louis now considers his diagnosis to have been 
precipitate; the diagnosis of a similar case, occurring^ at the pre- 
sent time, would, to say the least of it, be qualified and doubtful. 
Another case is recorded by Louis, in the first edition of his work, 
which was marked by most of the symptoms of typhoid fever, and 
on examination after death, no lesion was found in the elliptical 
plates, or the mesenteric glands. But here, again, it is important 
to remark, that the case occurred in 1823, when the diagnosis of 
typhoid fever was more doubtful, than it is at the present time ; 
and, furthermore, that the patient was not seen by Louis till the 
twentieth day of his illness. If to these circumstances it be added, 
that there was extensive, ancient disease of one of the kidneys, 
fatty liver, and considerable effusion under the arachnoid mem- 
brane, and into the lateral ventricles ; certainly we are justified in 
concluding, not that the case was one of typhoid fever, but that 
the diagnosis was incorrect. The second edition of Louis's work 
was published in 1841. In that, it is said, that no single new 
case, constituting even an apparent exception to the uniform re- 
lationship, between the group of symptoms upon which the diag- 
nosis of typhoid fever rests, and the abdominal lesion, had then 
been met with, either by Louis himself, Chomel, or Bouillaud. 
One case is briefly reported by Fouquier, which occurred at La 
Charite, in 1833, in which the symptomatology of typhoid fever 
seems to have been pretty clearly marked, and in which the ellip- 
tical plates and the mesenteric glands were found almost free from 
disease.^ A strong case, of apparent exception to the law of re- 
lationship, now under consideration, is reported by Prosper Dor. 
It occurred, at the Hotel Dieu of Marseilles, in 1833. The patient 

* Journal des Connaissances Medicales, Jan. 1834. 



DIAGNOSIS. 129 

was eighteen years old, and died on the eighth day of the disease. 
There were these symptoms, — headache; debility; loss of appe- 
tite; sleeplessness; then, epistaxis; great prostration of strength; 
soft irregular pulse; dry blackish tongue; sordes on the teeth; 
meteorism; diarrhoea; delirium; suhsultus tendinum, and picking 
at the bed-clothes. There was no cutaneous eruption. Certainly, 
in this case, the diagnosis, during life, would have been sufficiently 
clear and positive. An examination, after death, showed the in- 
testines to be healthy, but it showed, also, extensive disease of 
the urinary apparatus. The mucous membrane of the bladder 
was encrusted with a layer of urate of lime, and in the left kid- 
ney there was a considerable number of purulent depositions. 
Now, when it is considered, that diseases of these organs are very 
frequently attended, near to their fatal termination, with strongly 
marked typhoid phenomena, there can be no hesitation, I think, as 
to the disposition, which ought to be made of the foregoing case; 
no difficulty in assigning to it its proper position. It was clearly 
not typhoid fever; but an instance of disease of the urinary appar 
ratus, in which the typhoid symptoms, which often accompany 
the latter stages of the affections of this apparatus, were more 
numerous, and more closely resembling those of typhoid fever, 
than is often the case. Grisolle says that he has seen only a single 
exception to the relation of which I am speaking. 

I have been permitted, through the kindness of Dr. Hale, and 
Dr. J. B. S. Jackson, of Boston, to look over the notes of a case, 
which occurred in 1841, in the Massachusetts General Hospital; 
and which might seem to constitute an exception to this relation- 
ship. The patient was twenty-two years old. He entered the 
hospital on the 23d of June, 1841, after an illness of two weeks; 
during the first half of which time he kept about his work. He had 
pain in the head, back and limbs; dizziness; tinnitus aurium; 
prostration of strength ; loss of appetite ; daily, spontaneous, diar- 
rhoea ; abdominal pain, and epigastric distress ; tenderness over 
the right iliac region ; rigidity of the muscles, and tympanitic dis- 
tention of the abdomen; epistaxis; the rose-colored spots, and 
sudamina. He died on the 8th of August, having exhibited, for 
some time, symptoms of severe gastritis. The mucous membrane 
of the stomach was mamellonated, red, thickened, and ecchy- 
mosed; there was ulceration of the mucous membrane about the 
fauces, and root of the tongue; and the only alteration of the 
9 



130 TTFeOII> FETKIU 

^^fical plates of Ae iieiim coBsss^eA in tkeir gteast Ssdnctness, 
and pcriia^ a a^^ thicfaiiiiBg^ with a bi^it, sp&tteA, eceky- 
ifsduEss of two of die jAstcs; one of ^Mom two fiiet, and the 
finr feel, fioB tibe 3eo-€ecal Take. One or two ofters were 
affected, but in a ^^iter degree. A portion of tiie 
neadij a int in ki^^ extendi^ to wilkin ax inches oi 
rer-teiiBinaiion, was deqfdj ecdfjmased, in liands mnning 
Ae inteslme. A aii^le mesenteiie g^and, direcify opposite 
to lAc ileo-ceeal TalTe, was neaify as laxge as tlie aid of the 
tinuniiy led and aifi. The odier glands were scaicelj at all en- 
laiged. Tbe spleen was of medium size. 

tSile of an oiiiioiis and leadj e:i^]anation. Hie patient died af 
gastnlisy ei^^ wedra after tibe accessioftt of ^Ffdioid ferer. There 
is BO eYido^e^ ^tal Hie piimaij ai^etion here was of nnnsaal 
g i ati i ly ; Aise is no good reasim to think, that pci^tzTe nlecfaticr! 
of the JMf^sdrmal fidlides nsaaOy takes place in mild cases, an '.. 
fG^saps nol, in manj of modnate seweiitj; and in the one before 
nsy s8qppoai^ aach to hare been the case, sufficient time kati 
dapaed, fion die commencanent of the disease^ to accoont fow 
die raodeiale degree of alteration in the effi^piical plates and th f 
£ «cs a CBK ^ ^pktMfeaser^ I thimk, of 

Atd Ot mUrv^miamtarw h^tm kmUm gvod ftat, imi mU attirdy. 



hk die dismsaoa of dns qnealion, great stress has been la: i 
mpmt the obserralions of Andial, bj l&ose who deny or doabt the 
constant of 1^ connection, between the diagnostic spasms oi 
tjphoid lerer, and die pecoiiar leaon ci the d%idcal i^a^es . - 
A Tcij emaoij esaminalion, however, of the &ets cited by &is^ 
wiila-, win ^Mvw, condoarefy, Ukat tkeyjmai^y n^ 
it^maeex^ as Tmm heat dabteed fimm, tkem. The cases, 
he has n^oited, are fifteen in number, fie anai^es thes f 
intwodassi^; die first, eonasting of cases of what he caDscQn- 
tinoed Ibref with gastio-inlealinal l^ions, bat wkhont any aheiM 
lion of die dffiqptical plates; die second, eonsasling of cases of 
what he calk oonlinned fever, w^ioot any apprecbfale ksMm : f 
die d^es&ire tube. In ^be fixst dassj, are amtaiDed die hislories. 



DIAGNOSIS. 131 

generally short and incomplete, of seven patients. The fifth, 
sixth, and seventh, are the only ones amongst them that can be 
considered even doubtftd. The others are clearly enough not 
typhoid fevers ; in most of them, there was not present even the 
typhoid state. The sixth case looks like the true, petechial typhus, 
ahhough the history of the patient is too imperfect to justify any 
confident diagnosis. The seventh case appears to have been one 
of pneumonia, complicated wath erysipelas, following upon simple 
enteritis, and marked by typhoid phenomena. Certainly, there 
is not one amongst them, which, with our present means of diag- 
nosis, would be regarded, with any degree of certainty, before 
death, as a case of typhoid fever. 

An examination of the eight cases, included in the second 
class, is still more conclusive in its bearing upon the question now 
before us. There is not one amongst them, the diagnosis of 
which, so far as typhoid fever is concerned, can be looked upon 
as even doubtful. It is hardly too much to say, that neither of 
them could now be taken, by any possibility, for a case of typhoid 
fever. I will briefly enumerate the diseases. The first, case 
forty-sixth of the volume, was phlegmonous erysipelas of the arm, 
occurring in a soldier, thirty-five years of age ; the second was 
gangrene of the right leg, in a patient fifty-three years old, suffer- 
ing with organic disease of the heart ; the third was inflamma- 
tion, either chronic or acute, of the right kidney, and the mucous 
membrane of the bladder, in a patient sixty years of age ; the 
fourth was extensive suppuration of the prostate gland ; the fifth 
was latent pneumonia, in a woman eighty-one years of age ; the 
sixth and seventh were affections of the brain, one of them in a 
patient eighty-one years old; and the eighth was gangrene of the 
lip, accompanied with extensive phlebitis, and numerous purulent 
depositions in the lungs. This simple statement of these cases 
precludes the necessity of any further remarks upon them. Mani- 
festly, they have no connection with the question of relationship 
bet\veen the usual symptoms of typhoid fever, and the alteration 
of the elliptical plates of the ileum; and yet they have been, more 
perhaps than any others on record, relied upon to prove the want 
of any constancy in this relationship. It is certainly very im- 
portant, tjiat this typhoidal state of the system, occurring in con- 
nection with many diseases, should be distinguished from typhoid 
fever. Unless this is done, there is an end to all positive and phi- 



132 TYPHOID FEVER. 

losopliical diagnosis. Since wiiting this history, I have seen a 
patient presenting these phenomena, amongst others ; prostration 
of strength; slight suhsultus tendinum; tympanitic distention of 
the abdomen; diarrhcea; gurgling on pressure ; a dry, red, cracked, 
tongue; sordes on the teeth ; wandering delirium ; and sudamina 
about the neck. Here were many of the most characteristic ele- 
ments of t>-phoid fever; but the disease was, clearly and unequi- 
vocally, puerperal peritonitis. These typhoid phenomena, as I 
have already said, are often present in many diseases ; in small 
pox; in scarlatina; in asthenic pneumonia; in softening of the 
brain; in some diseases of the kidneys; in erysipelas; in dysen- 
tery, and so on ; but under these circumstances, where their cort- 
iiection with these several affections can he discovered, they ought 
not to he confounded with typhoid fever. It was from disregarding 
this obvious principle, that Andral was led to the conclusion which 
I have been examining. 

Barthez and Rilliet, in the course of some observations on the 
disease, as it occurs in children, published in the Journal des 
Connaissances Medico- Chirurgicales, for 1841, report one or two 
apparent cases, not attended by the characteristic lesion. 

There is one other point in the discussion of this question which 
it is important not to overlook. It has been said that these intes- 
tinal lesions, strongly marked and striking as they may be, are by 
no means confined to cases of typhoid fever, — that they are fre- 
quently found in other and quite dissimilar diseases; so that, ad- 
mitting even that they constitute the constant anatomical lesion of 
typhoid fever, they are still not distinctive and characteristic, since 
they are common to it and to other diseases. 

There is a single reply to these objections, which seems to me 
entirely satisfactory and conclusive. The diseases, other than 
t}'phoid fever, in which alterations of the intestinal glands are 
most frequently found, are tubercular phthisis, scarlet fever, and 
certain forms of cholera. Now in all these cases, it is quite suffi- 
cient to say that the condition of the glands is obviously and ma- 
nifestly different from what it is in r^-phoid fever. In phthisis, the 
intestinal ulceration is clearly tubercular, depending upon the pre- 
sence and development of this morbid product in the intestinal 
glands. Besides this fundamental difference in the very nature 
of the lesion, the inflammation and ulceration in phthisis are chro- 
nic in their march, and the appearances of the lesions differ in 



DIAGNOSIS. 133 

many other respects in the two diseases. As to scarlet fever, and 
some of the forms of cholera, it is enough to say, that the only 
changes of the intestinal glands, observed in these diseases, have 
consisted in a moderate thickening, with or without redness and 
softening of the follicles, and that even these changes are far 
from constant. In none of these diseases, are there the peculiar 
changes of the intestinal glands found in typhoid fever, while the 
mesenteric glands are very rarely at all affected. 

In the consideration of this question, as of all others, which are 
still legitimate subjects of discussion, and controversy, I have 
sedulously endeavored to avoid any thing like a partisan, or one- 
sided, examination. I have not intentionally overlooked, or put 
aside, or warped to my mere wishes, if I have any such unfriendly 
and treacherous guides and counsellors in the search for truth, 
any of the evidence bearing upon the subject. I have adduced 
all the cases, that I have been able to find, which might seem to 
constitute exceptions to this general relationship, or to throw doubts 
upon its invariableness ; and the conclusion to w^hich I am irre- 
sistibly led is this ; that the connection, between the diagnostic 
symptomatology of typhoid fever, and the enter o-mesenteric lesions^ 
iSf I will not say absolute and invariable, but as nearly so, as the 
connection between the diagnostic symptoms, and the characteristic 
lesions of any given disease, whatever, in the nosology, in which 
this connection is not established by positive, physical, signs. 



134 



CHAPTER IX. 

THEORY. 

I believe that it will be a phenomenon in medical writings, to find an essay on 
such a disease as fever, unattended by a theory of its proximate cause. Yet were 
it as well, if the professor who spends months in exciting the wonder or applause 
of a juvenile audience, with phraseology which he does not himself understand, 
would substitute for all this waste of words and time, the confession of his own 
and the general ignorance. — John Macculloch. 

The most positive thing that can be said, under this title is, 
that the materials for a complete and philosophical theory of fever, 
or theory of any individual fever, using this phrase in its ordinary 
acceptation, do not exist. Such a theory presupposes and involves 
a knowledge of the intimate processes and relations of the living 
powers, which has not yet been attained. It is very questionable 
even, whether such knowledge is attainable. 

In order to see clearly the truth of these observations, and the 
extent of this truth, let us inquire, for a moment, what some of 
the elements are, which must go to make up this knowledge; 
what their nature is, and in what they consist. In the first place, 
we must know what the actual, efficient, causes of any given 
fever, or form of fever, are. We must know what that agency, 
or combination of agencies, is, which, being present, brings into 
existence, originates, sets in motion, that concatenation of dis- 
ordered actions, that complex combination of morbid processes, 
which constitutes the fever. We must know in what manner 
these agencies act; w^here they make their impression; and in 
w^hat the modifications consist, which they w^ork in the living 
organization, and its properties. Of all these things, we are 
utterly and profoundly ignorant. In the second place, we must 
know the seat and character of all these processes and modifica- 
tions themselves ; their peculiarities ; their tendencies ; the diflfer 
ences,, which exist between them, in the several forms of febrile 
disease. We must know their relations to each other. We must 



THEORY. 135 

know which amongst them are primary and essential ; which are 
secondary and accidental. We must know the parts which they 
severally play in the production of the integral disease. Of these 
things, also, as of the causes offerer, and their mode of action, it 
is not too much to say, that if we are not wholly and profoundly 
ignorant, we are so to a great extent. They are but very par- 
tially and imperfectly known to us. They are known to us, rather 
analogically, if I may so speak, and by comparison with other 
morbid processes, than absolutely and positively. We can see 
wherein they differ, in many respects, from these other processes, 
and wherein they resemble them. With these limitations, and 
under the conditions implied by these remarks, there is no reason 
why we may not attempt to commence the foundation of a theory 
of fever. But, in the present state of science, it can only be an 
attempt at a commencement. We may endeavor to interpret the 
connection and relationship, which observation has shown to exist 
between certain phenomena, or groups of phenomena. We can 
do nothing more. 

It ought to be unnecessary to say, that even this can be doae, 
only by confining ourselves to a single well defined, individual 
form of fever. Under the simplest conditions, and where alone 
it is, in the nature of things, at all possible, we shall find this in- 
terpretation, or theory, sufficiently obscure and difficult. When 
attempted, as has generally been the case, under other conditions, 
it has proved utterly futile; when applied, as these interpretations 
and theories have generally been applied, to unascertained and 
imaginary states of the system, they have always degenerated, 
necessarily, into the idlest of all conceivable speculations. There 
is no such individual disease as that which has always been ex- 
pressed, and which is still expressed by the term fever. How 
then can there be any tJieory of fever? There are many separate 
diseases, to which this generic name is properly enough applied, 
on account of certain general analogies, which exist between them. 
Bat the disordered actions and processes, which constitute one of 
these diseases, may differ essentially ; and, as far as we can ascer- 
tain, in most cases they do so differ, from those which constitute 
another of these diseases. The theory of one fever, then, must he 
wholly, or to a great extent, inapplicable to another. The elements 
which enter into the composition of one problem are not to be 
found in the other, or they are present in different proportions. 



136 TYPHOID FEVER. 

The word fever, when used, as it commonly is, to designate a dis- 
ease, has no intelligible signification. It is wholly a creature of 
the fancy; the offspring of a false generalization and of a spurious 
philosophy. What, then, can its theory be, but the shadow of a 
shade ? 

If the true theory of disease be such as I have represented it, 
we should naturally look, in its application to any individual and 
separate form of disease, first and principally, to those phenomena, 
which are most constantly present, and which seem to constitute 
its most important elements. According to this rule, and in rela- 
tion to the subject immediately before us, the theory of typhoid 
fever, the first inquiry would naturally be, what is the nature, and 
what are the relations, of its characteristic lesion — that of the 
elliptical plates of the ileum. A satisfactory answer to these 
questions would so far settle the theory of the disease. 

What is the nature of this alteration of Peyer's glands? Does 
it consist in an inflammatory action, and its results? If so, is 
the inflammation common, and simple; or has it something pecu- 
liar, and specific, in its character? W^e can hardly hesitate, I 
think, in attributing this lesion to inflammation. We know nothing 
of any other morbid process that can produce similar results. In 
its early stages, we find the tissues w^hich are its seat, tumefied 
and reddened ; subsequently, ulceration takes place ; and if life 
is not destroyed, there is abundant evidence, that the restorative 
process is set up, and the lesion removed by complete cicatriza- 
tion. Their enlargement, softening, redness, and, in some in- 
stances, the presence of pus in their substance, are equally 
sufficient proofs, that the affection of the mesenteric glands, is 
also, of an inflammatory character. But, as to the second point, 
it seems to me, that all the analogies in pathology tend to show, 
that this inflammation is not common, but specific. It is circum- 
scribed, and not diffused, as ordinary inflammation of the mucous 
tissues usually is. It does not ofl;en lose itself gradually, shading 
off* into healthy membrane. The morbid process almost constantly 
extends to the subjacent cellular membrane, which is almost 
never the case in common mucous inflammation of an acute cha- 
racter. Its tendency to rapid ulceration, and the appearances of 
some of its morbid products, would also seem to show, that it has 
something special, and peculiar, in its nature. Is it not also phi- 
losophical and fair to infer something in corroboration of these 



THEORY. 137 

views from the observations of Andral and Gavarret in regard to 
the condition of the blood in different diseases? They have found, 
from extensive and careful examination, that in all diseases con- 
sisting of common, open, frank inflammation, in any of the organs ; 
or complicated with such inflammation; the relative quantity and 
proportion of fibrine in the blood is increased ; while in diseases 
of an opposite character, and under opposite circumstances, — in 
the exanthemata, for instance, — the fibrine either merely main- 
tains its natural proportions, or is diminished in quantity; a con- 
dition, as we have already seen, characteristic of the blood in 
typhoid fever. 

In regard now to the relation between this lesion of the ellipti- 
cal patches on the one hand, and the disease, considered as a 
whole, on the other; or, between the lesion and the symptoms; 
the simplest view to be taken is that which makes the disease 
consist, essentially, in the lesion ; and which refers the symptoms 
to the lesion as their cause. This doctrine makes typhoid fever, 
not an essential or idiopathic fever, but an enteiitis, or a follicular 
enteritis, or a dothinenteritis ; and assigns to it a nosological posi- 
tion amongst the local phlegmasiaB. This is a modification, merely, 
of the great doctrine of Broussais ; and a modification only so far 
that it does not include the mucous membrane of the stomach in 
the lesion. It is still held, partially at least, by some French 
pathologists of the present day. It has been, strangely and un- 
accountably enough, even by men who have read his books, attri- 
buted to Louis. Dr. O'Brien, of Dublin, in one of his hospital 
reports, when speaking of this subject, says, — "M. Louis, in 
particular, has adopted the theory of Broussais in its fullest ex- 
tent."^ The same misapprehension has been fallen into even by 
such a man as Dr. Christison. It is, however, so far from being 
true, that Louis has ever adopted the doctrines of Broussais, in 
relation to the nature of fevers, that no other observer has done 
so much in overthrowing his peculiar principles. He has ever 
been the most formidable and successful antagonist of that extra- 
ordinary man ; opposing in the calm confidence of a truth-loving, 
and truth-seeking spirit, to the arrogant assertions, and to the 
seductive generalizations of the highest genius, — maintained and 
vindicated, as they were, by a strength and an eloquence of Ian- 

» Dublin Med. Trans., p. 313. 



138 TYPHOID FEVER. 

guage unequaled in the annals of medical literature, — the impreg- 
nable and serried array of facts and their relations, carefully and 
positively ascertained. One objection to this view of the nature 
of typhoid fever consists in the circumstance, that there is no 
uniform proportion between the extent of the local disease, and 
the severity of the symptoms. There are many fatal cases, in 
which the intestinal lesion is very limited in extent; there are 
others, where the whole character of the disease has been un- 
usually mild, and in which, when life has been destroyed by 
some secondary and accidental complication, the alteration of the 
intestine has been found to be very extensive and profound. This 
objection, although sound and reasonable, ought not to be considered 
conclusive. Notwithstanding the exceptions just referred to, it is 
not certain, that there is not, after all, a general correspondence 
between the gravity of the local lesion, and the severity of the 
disease. Besides, even in affections manifestly of a strictly local 
character, in which the disease consists in the local lesion, it is 
far enough from true, that there is anything like an exact and 
uniform proportion between the extent of this lesion, and the gene- 
ral disturbance of the economy. The degree of this disturbance, 
constituting the general symptomatolog)', is influenced by a variety 
of causes, other than the local disease; so that although we shall 
find abundant reason, I think, for rejecting the view of which I 
am speaking, let us be careful not to do so for false reasons, and 
on wTong grounds. 

I shall now allude to some of the considerations, which go to 
show, that the local lesion of typhoid fever is not primary, but 
secondary ; that, instead of beino^ the sintjle cause and origin of 
the disease, it constitutes only one of its elements; and is itself 
dependent upon some other and ulterior morbid condition as its 
cause ; the seat, nature, and operation of which are not known to 
us. It may be observed, that if the view which has been taken 
of the specific character of the inflammation, entering into the 
composition of the follicular lesion, be looked upon as sound, it 
constitutes, in itself, a cogent reason for the correctness of the doc- 
trine above stated. Indeed, it must constitute the principal rea- 
son ; and in addition to what has already been said upon this sub- 
ject, I will only present one other consideration, which has been 
much insisted upon, in support and illustration of the view before 
us, by Chomel. He says, that one of the most constant and uni- 



THEORY. 139 

form characteristics of secondary lesions^ consisting generally of 
specific inflammations, is the fact of their being disseminated ; of 
their occupying numerous and circumscribed spots in the tissues 
and organs of the system. The most striking examples of this 
pathological law are to be seen in the eruptive fevers ; in measles ; 
scarlatina ; small-pox ; and the oriental plague. The same law 
shows itself, also, in other cutaneous inflammations ; in urticaria ; 
in varicella ; in the successive crops of furuncles, which are 
sometimes observed, and so on. It is seen, further, in some 
affections of a different character; such as scrofula; syphilis; and 
the several varieties of scirrhus and cancer. All these numerous 
diseases, though they differ very widely from each other, in many 
respects, have this character in common ; that the local inflam- 
mations, which accompany them, are disseminated ; that they oc- 
cupy a considerable number of defined and limited localities. 
There are several other particulars, in which the members of this 
extensive family of disseminated lesions agree with each other ; 
all of Avhich tend to exhibit their specific character, and their sub- 
ordinate relations. They depend upon specific causes. They 
cannot be produced at will by any of the ordinary excitants of 
common inflammation. In many cases, these causes are gene- 
rated by the morbid process itself; and so the diseases are trans- 
mitted directly from one individual to another, and are thus per- 
petuated. In other cases, the origin of the cause is unknown. 
They have, generally, a more or less regular march, and determi- 
nate duration; in many instances, going through a series of suc- 
cessive stages ; and if life is not destroyed in the course of the 
process, terminating, naturally, in a return to a healthy condition. 
This march and duration are but very little under the control of 
art ; the first cannot be much modified, nor the second much 
abridged, by the use of remedies; and so far even as these eflfects 
can be produced, they must be produced by means acting, not 
directly upon the lesions themselves, but upon the general system. 
Now, in every respect, the intestinal lesion of typhoid fisver corre- 
sponds to this class of pathological alterations. It is disseminated ; 
occupying the same glandular tissue at different points of the in- 
testinal mucous surface; it cannot be artificially produced by any 
of the common causes of inflammation ; it depends upon a specific 
but unknown cause ; it has a regular march, and a determinate 
duration; passing through its several stages, and terminating, if 



14Q TYPHOID FEVER. 

life is not destroyed, in a return to health; and, finally, this pro- 
cess is but little under the control of art. It is strongly corrobo- 
rative of the soundness of this view, that in a disease, closely re- 
sembling this in many of its symptoms, I mean the contagious 
typhus, there is no constant local lesion of any sort to which the 
symptoms can be referred. Certainly, it needs no elaborate argu- 
ment to show how clearly all these circumstances indicate, that 
the local lesions in this class of diseases, are peculiar in their na- 
ture; secondary and dependent in their relations; constituting, not 
the primary and essential cause, hut only one of the pathological 
constituents of the particular diseases in which they severally occur. 

Some pathologists have adopted the doctrine, that the unknown 
cause of typhoid fever acts primarily upon the nervous system, 
producing some unascertained lesion of innervation, which, in its 
turn, gives rise to disturbances and alterations in the other organic 
apparatuses and tissues, and in the fluids ; these aggregate dis- 
turbances and alterations constituting the disease. This doctrine 
may be the true one ; but in the present state of science it must 
be regarded as wholly hypothetical ; and there are some consider- 
ations which militate strongly against its probability. 

Another theory is that w^hich places the primary and funda- 
mental alteration in the blood. We may be justified, I think, in 
saying, that at least this theory has more claims upon our atten- 
tion, and is more probable, than that of which I have just spoken. 
It is already demonstrated, that in many cases of typhoid fever, 
and in other diseases, to which it is more or less nearly allied, 
especially by the common presence in them all of what has been 
called the typhoid state, or the typhoid element in pathology, im- 
portant and peculiar changes have taken place in this fluid. 
These changes may have been primary and essential. There is 
good reason to think, at any rate, that they play a very important 
part in the pathology of these diseases. They deserve further 
investigation, and they ought never to be overlooked ; but their 
actual relations to these diseases are very far from being ascer- 
tained. In another class of affections, the acute phlegmasiae, we 
find important alterations in the composition and character of the 
blood, which are, pretty evidently, the result of the disease ; they 
are secondary and not primary in their relations. Such may be 
the case, also, in typhoid fever, and its analogous diseases. I am 
disposed to look favorably upon this partial return of the old 



THEORY. 141 

humoral pathology, and to hope much from its cultivation and 
development; but I do not think that we can yet apply it very 
confidently or extensively to the interpretation of morbid pheno- 
mena. This, upon the whole, it seems to me, is as far as we can 
go, safely and philosophically, in our attempt to explain and to 
account for the morbid processes and alterations, which constitute 
typhoid fever; or to establish, in other words, a theory of the dis- 
ease. 



142 



CHAPTER X. 

TREATMENT. 

There are few diseases of equal frequency, and importance, 
the treatment of which is more unsettled than that of typhoid 
fever; and there is, certainly, no disease, the therapeutics of 
which has, within the last few years, attracted more attention 
than this. Various, and to some extent, opposite modes of 
management have been adopted, by different practitioners ; they 
have been conducted on a large scale, for the most part in a fair 
and impartial spirit, and under circumstances favorable to the 
discovery of the truth ; but they have not yet resulted in the esta- 
blishment of any uniform and satisfactory method of treatment. 
There is no unanimity in the opinions and conduct of different 
practitioners. 

Under these circumstances, it is somewhat difficult to decide 
upon the best course to pursue, in treating of the subject, in a 
work like the present. It is impossible, within any reasonable 
limits, to describe, in detail, all the different plans of treatment, 
that have from time to time been adopted, or that are still pursued ; 
together with their actual or alleged results. Still, the complete- 
ness of the work, and the interests of humanity alike require, that 
the actual state of our science, in this respect; the sum and the 
result of our observations and researches, so far as these can be 
ascertained, should be fully and fairly stated. I shall therefore 
endeavor to do this, as far as it is possible. I shall describe the 
several modes of management, which have been most extensively 
followed, and most thoroughly studied, by those leading and dis- 
tinguished men, who have been most favorably situated, for the 
investigation of this subject. In doing this, I shall not often enter 
into any detailed and particular statement of the effects of indi- 
vidual remedies in single cases, or upon single symptoms, which 
different physicians allege that they have seen produced. It will 
be sufficient for my purposes to state, in general terms, the results 
of their investigations and analyses. 



TREATMENT.— DR. JACKSON'S METHOD. 143 



ARTICLE I. 



Dr. Jackson, of Boston, after having been for many years an 
extensive, and careful observer of typhoid fever, both in public 
and in private practice, and after an accurate and circumstantial 
re-examination and analysis of the effects of remedies upon the 
disease, as they were exhibited in the wards of the Massachusetts 
General Hospital, arrives, finally, at the following conclusions, 
which it is impossible to give so w^ell, in any other way, as in 
his own words. They would suffer by any alteration or abridg- 
ment. 

*' First, that on the attack of this disease, the patient should 
immediately desist from labor and mental exertion, abstain from 
food, except of the simplest, liquid kind, and place himself in 
bed, or, at least, in a state of repose. 

"Second, that free evacuations should be made at the begin- 
ning, and that in doing this, a day is important. It is better, 
that they be made the first day than the second, better on the 
second than the third ; but that it is especially important that they 
should be made as early as the third day. That an emetic of 
tartarized antimony should first be given, and then an active 
cathartic, or the two in combination. If there is constipation at 
the time, an active enema, given at first to disembarrass the 
bowels, would no doubt facilitate the action of an emetic. If the 
vomiting and purging are not followed by great relief, venesection 
should be practised on the following day, unless the constitution 
should be very feeble, or the case very mild. 

" Third, if the disease has not subsided after the evacuations, 
tartarized antimony should be given every tw^o hours in increasing 
doses, after the method of Odier of Geneva. Meanwhile the 
bowels should be kept open, and, for two or three of the first days, 
it would be well that calomel should enter into the medicine used 
for this purpose ; not, however, giving more than one moderate 
dose in a day. It should be noted, however, that, usually, after 
the antimony has been given for forty-eight hours, this will act 
sufficiently on the bowels, and that sometimes it must be restrained 
by opium. 



144 TYPHOID FEVER. 

" Fourth, that, when the disease subsides early under any 
active treatment, it is quite essential that the patient should be 
restrained from solid food for two or three days, at least, after he 
has an appetite for it ; and that he then use vegetable food in 
small quantities, for two or three days more. Likewise that he 
should not be allowed to make any efforts of either body or mind, 
until his convalescence is fully established. By this it is not 
intended that he should be confined wholly in bed, but that he 
should be confined to his chamber, and not allowed to talk on 
business, nor on any interesting subject. 

" Fifth, that evacuations, vomiting and purging at least, may 
be resorted to with advantage in the second week; and that per- 
haps some benefit may be obtained from antimony in small doses, 
when commenced in that week. But, that, after that period, no 
active treatment should be employed, or none which will cause 
any serious inconvenience to the patient. 

" Sixth, as to diet. There is no point, probably, on which all 
practitioners are more agreed, than that food should be withheld 
from persons affected with the disease in its early period, except 
only the mildest, or most bland, liquid articles. Probably food 
would be injurious in its early period, at least, if it could be 
digested. But it cannot be digested perfectly, and often not at 
all, and that alone should forbid the use of it. When the disease 
is arrested or mitigated by treatment, it is very certain that an 
indulgence in the use of food is most commonly injurious, and 
that the cautions already stated are not too severe. When, how- 
ever, the patient is fully reinstated, he must be allowed some extra 
food for the recovery of his flesh and strength. This must be done 
cautiously; but an extreme and protracted abstinence is injurious. 
When the disease runs its usual course, and the appetite for food 
returns, is there any danger in the indulgence of it? To this 
question I answer, in proportion as the return of appetite takes 
place early, more caution is necessary. If it takes place at, or 
about the end of the third week of the disease, if it is decided, and 
if it is accompanied by a cleaning of the tongue, almost any arti- 
cle, which the patient craves, may be allowed him with safety. 
The appetite is usually a sufficient guide as to the quality of the 
food; but not as to quantity. In a large proportion of cases it 
will be found a most uncertain guide, as to quantity. Hence it 
is necessary to begin with small quantities, and to increase gra- 



TREATMENT.— DR JACKSON'S METHOD. 145 

dually. It is equally necessary to make the intervals long between 
the portions of solid food, which are given in the early period of 
convalescence. At first, there should be one portion of solid food 
in the day; the next day, if every thing is favorable, two portions, 
with five or six hours between them; and two or three days later, 
watching the etfects, three meals may be allowed. But we are 
not merely to feel the pulse under these circumstances, to see if 
the fever has increased. The danger is not, I apprehend, that the 
system will be too suddenly nourished. It is that the enfeebled 
organs of digestion may not be able to digest the food. We must, 
therefore, watch all the signs which refer to those organs. Only, 
if the head should ache, or other organs be disturbed, we should 
remember that the prominent signs of indigestion are often shown 
elsewhere than in the stomach, and stop the food till it appears 
whether this is not now the case. It is also to be constantly re- 
membered, that constipation of the bowels will be followed by indi- 
gestion, and that evil must, therefore, be guarded against. 

" Seventh, cordials. On this, as under the last head, I must 
give the convictions, arising from the most careful observations I 
have been able to make in many years. I cannot adopt the more 
accurate mode of the numerical system. Nor in this case could 
this system be usefully followed, unless with the greatest atten- 
tion to the state of each case. It has appeared to me that we 
should not adopt the rule to give cordials, nor to withhold them, 
in every case. When a patient is induced to take cordials, re- 
luctantly, they seldom benefit him, and are often followed by 
injury. When he is greatly enfeebled, at a late stage of the dis- 
ease, he may be safely asked if he wishes for them, and if he does, 
he may try them; they will seldom hurt him then, if he takes no 
more than is grateful to him. When he spontaneously demands 
them, as late as the third week, they will almost always be found 
useful. Now, in following these rules, I have occasionally found 
a patient, who would take a large quantity of some cordial liquor. 
But this has been rare. Few take them longer than two or three 
days, and the majority of patients do not take them at all. It is 
proper to add that by cordials I mean vinous liquors. I have most 
commonly found cider grateful in the first instance, beginning with 
an ounce, two or three times a day, and increasing according to 
the effects. Sound beer, or ale, is more rarely, but sometimes, 
grateful. In patients much exhausted, however, the strong foreign 
10 



146 TYPHOID FEVER. 

wines, Sherry, Port, and Madeira, are found most useful. These 
articles may be diluted, or may be employed to season articles of 
diet, or may be given alone, according to the taste of the patient."^ 

It may be added here, that Dr. Jackson, during the early period 
of his practice, in common ^Yith most of the New England physi- 
cians, made use, also, of calomel in the treatment of typhoid 
fever. This article generally made a part of the purgative given 
at the commencement of the disease. 

It was afterwards continued in small, and frequently repeated 
doses, combined, according to circumstances, with ipecacuanha, 
or antimony, or opium. Moderate ptyalism was looked upon as 
a favorable occurrence, although profuse salivation was dreaded. 
Dr. Jackson's faith in the usefulness of calomel was shaken, a 
few years after the commencement of his practice; when the 
Massachusetts General Hospital was opened, he still resorted to 
it occasionally, during the first few days of the disease, and par- 
ticularly when any secondary inflammation supervened; but con- 
fidence in the specific power of the medicine grew less and less, 
and since 1830, its use in the hospital has been nearly abandoned. 
Dr. Jackson informs me, that his convictions of the efficacy of 
early evacuations in the treatment of typhoid fever, founded on his 
experience in private practice, are not less strong, than those 
which rest on the careful analysis which he has made of the 
results of his hospital cases. 

ARTICLE II. 



I shall now give a summary of the mode of management, fol- 
lowed in typhoid fever, by the late Nathan Smith. He begins 
his remarks on the treatment of this disease by saying, that he 
had never seen a single case, in which he was satisfied that he 
had been able to cut short and arrest its progress; and that, in 
all cases where the disease is going on regularly in its course, 
without any symptom denoting danger, and without any local 
distress, active interference will be likely to do more harm than 
good. Under such circumstances, he thinks no medicine should 

* Dr. Jackson's Report on the Typhoid Fever. Med. Com. of the Mass. Med. Soc., 
-vol. vi. part iL p. 168, et seq. 



I 



TREATMENT.— DR. NATHAN SMITH'S METHOD. 147 

be given. He also expresses his conviction, that all powerful 
remedies or measures, made use of in the early stage of the dis- 
ease, are very liable to do harm, and that those patients who are 
treated with them in the beginning of the fever, do not hold out 
so well in its latter stages. He says, that he has seen many 
cases, in which persons in the early stages of this disease were 
moping about, not very sick, but far from being well, and who, 
upon taking a dose of tartrate of antimony, have been immediately 
confined to their beds.^ He adds, in another place, these remarks : 
"In cases of simple, mild typhus, where there is no nausea at the 
stomach, no pain in that region, where the heat is moderate, and 
the pulse not greatly altered in frequency, I am clearly of opinion, 
that we had better leave the disease to cure itself, as remedies, 
especially powerful ones, are more likely to do harm, than good. 
In such cases, the patient gets along better without medicine, 
than with ; all that is required is to give him simple, diluent 
drinks, a very small quantity of farinaceous food, and avoid, as 
much as possible, all causes of irritation." 

Dr. Smith opposes the plan, then adopted by some New Eng- 
land practitioners, of general and almost indiscriminate blood- 
letting, at the commencement of the disease. He would bleed 
only where there was "uncommon pain in the head, accompanied 
with great heat in that part, a sense of fullness, and a throbbing 
of the tempA'al arteries; or marks of congestion in the viscera of 
the thorax, such as pain in one or both sides of the chest, increased 
by a full inspiration." Under these circumstances, he thinks, 
that the loss of from twelve to sixteen ounces of blood will often 
mitigate the severity of the disease, and enable the patient to go 
through it with more safety. The immediate effects of bleeding 
have not appeared to him very obvious; and he says, that where 
the pulse is very frequent, the operation is seldom or never 
attended with any advantage. 

Emetics are recommended by Dr. Smith only where there are 
nausea and oppression at the stomach, either at the commence- 
ment or during the progress of the disease. His favorite articles 
are ipecacuanha, eupatorium, or sulphate of zinc, given either 
singly or combined. Tartrate of antimony he looks upon as an 
inappropriate and unsafe remedy. The bowels, he says, should 

1 Smith's Medical and Surgical Memoirs, p. 72, et seq. 



148 TTFHCTD FEVER. 



ei . ^ z. :i:i rs irir ^ '.::'. ? : :?. : ^^ s j^etimes injnrious. 
They may as well, tz -'-^-^s. . ? ensed with. 

S*in}^J?^Dg remedies ^1"=- zr: - 7. : - : t nal heat, for 

;t :^ of exciting active perspiration, have always appeared 

t :- : :e attended with bad consequences, a: " :: '5 cf 
t jie ^5 d ii i . Opium, for the purpose of procuring : t s : ? .. / : e :- 
ness during the night, when it is not contraindicated by high 
fr :' T xcitement and pain in the head, and in combination with 
I 7 : : B^nha and camphor, to restrain immoderate dianhcEa, he 
5-5. n?' : r used to advantage. He has seen, in many instances, 
verr sf::: s t :^5 fiom the specific a: : :. :: rcury, but no 

t ene£:. C : : 1 he has found to produ r ^ : - dect in some 
cases, wii T f surfoce was cold, and also where there was 
}^^^: :: : :_i Tir :: ineral and vegetable acids, the alkalies, re- 
:::r^:: :. 5. ?5 :it are called, such as sulphate of magnesia, 
super-tartrate and nitrate of potass, he regards as unimportant or 
questionable remedies. 

The most effectual refrigerant and febrifoge, in the hands of 
Dr. Smith, consisted in the free use of cold water, externally. 
He is very warm and decided in his commendation of this re- 
medial measure. He says that there is nothing else so powerful 
in allaying morbid heat of the surface, in diminishilig thirst, and 
in quieting restlessness and agitation. He directs the body of the 
patient to be uncovered, and then to be sprinkled or dashed re- 
peatedly, with pure, cold water. He allows cold water for drink, 
as freely as the patient may desire, during the whole course of the 
disease. 

I':. Sni .1 closes his account of his expectant and rational sys- 
't" :: '7 /lie::" in typhoid fever, with the foUowing directions 
: : Mt It i ::^ are of the patient. 

•• V^ nen an individual is first taken sick with typhous fever, 
^5 5: : :.i ^xpect a disease of considerable length, and mak« our 
c : _ -1 7 '5 accordingly. If the thing is practicable, he should 
: 7 -7 ious room, the larger the better. His bed should 

7 5 ::?':?. especially if it is in the warm season; and 

i >--::.: rd in the comer, but brought out into the 

r: :ii. We 5 ntrive to have a current of air pass over the 

bed hj means 01 uovrs and windows. * * * In the warm season 



TREATMENT.— CHOMEL'S METHOD. 149 

of the year, the windows should be kept open, night and day. 
All the furniture should be removed, except such articles as 
are required for the patient's use. The windows should be dark- 
ened, or something opposed to the light, in such a way as to still 
admit the air. The room should be kept as quiet as possible, 
since noise is injurious, and no more persons should be admitted, 
than are necessary to take care of the patient, which will, if he 
is very sick, require the labor of more than one. 

" The room should not be carpeted, and the floor should be often 
washed with pure water, or soap and water, and in the hot sea- 
son, it, as well as the walls, may be kept wet with water during 
the heat of the day. 

*' Cleanliness is absolutely essential to the patient's comfort, and 
no dirty dishes or useless medicines or food should be suffered to 
remain in the room. All excrementitious matter should be re- 
moved immediately. In the warm season of the year, the bed 
and body linen should be changed every day, and in the cold, 
every other day at farthest. 

" The patient's body and limbs should be cleansed every day 
with a piece of sponge and warm water, or soap and water. If 
a male he should be shaved everyday, or every alternate day, and 
if a female with long thick hair, it should be cut off or thinned, 
so as to leave but little of it the full length."^ 



ARTICLE III. 

chomel's method. 

The treatment of typhoid fever has been, especially for the last 
twenty years, a subject of great interest amongst the physicians 
of the large hospitals of Paris. It was in these institutions, that 
the symptomatology, diagnosis, and pathology of the disease were 
first thoroughly studied ; the opportunities which they offer for a 
careful trial and comparison of different modes of management 
are unequalled ; and these opportunities have been very faithfully 
made use of by a considerable number of cautious, accurate, and 
philosophical observers. Amongst them maybe mentioned, par- 
ticulai'ly, and this without making any invidious distinction, Cho- 

■^ Smith s Medical and Surgical Memoirs, pp. 95. 96. 



150 TYPHOID FETER. 

mel and Louis. Chomel has been for many years attached either to 
LaCharite, or to the Hotel Dieu; he has grown old in the constant 
and conscientious study of disease; and, now, in the ripe maturity 
of age and experience, is unsurpassed in the capital of France, as 
a man of practical sagacit}- and skill. I shall first give a summan 
of his practice in this disease.-^ 

His treatment is, for the most part, what is called rational, or 
symptomatic; that is, it is adapted, as far as common sense and 
experience enable us to do this, to the rarjing state and condition 
of the patient, in different forms of the disease, and in the seyeral 
stages of its progress. 

Simple and benign cases may be rery safely trusted, he says. 
to refreshing drinks, such as lemonade, currant water, orangr 
water, or pure water, taken at short intervals, and in such quan- 
tities as the patient may desire; emollient fomentations or poul- 
tices upon the abdomen, when this is painful ; sponging the sur- 
face of the body with vinegar and water, or cold affusions, if the 
skin is hot; mucilaginous injections, several times a day; cold 
applications to the head, when this is the seat oi pain, and hot 
poultices or sinapisms, if there is a disposition to drowsiness and 
disturbed sleep. These measures, combined with fresh air, clean- 
liness and quiet, will generally conduct the patient safely through 
this form of the disease. Still Chomel is inclined to think, that 
even in these cases, a single moderate bleeding, at the commence- 
ment of the fever, while it diminishes somewhat the severity of 
the headache, and shortens the period of its continuance, may 
also be of some utility in preventing the development of ulterior 
complications, and exert some favorable influence upon the march 
and termination of the disease. If the headache, or the pains in 
the abdomen, are severe, leeches may be applied, below the mas- 
toid processes, for the former, and near the anus, for the latter. 
If the bowels are constipated, they may be opened by some gentle 
laxative ; if the diarrhoea is troublesome, it may be moderated by 
rice water, injections of starch and water, and so on. 

In the inflammatory form of the disease, Chomel adopts a more 
decided, antiphlogistic course, adapted to the intensity of the 
symptoms, and to the age and vigor of the patient. The bleed- 
ing is to be repeated once or twice, leeches applied where they 

* Le§or» de Clinique MedicEde. Pai A. F. Chctrae-ljp. 449, et sej. 



TREATMENT.— CHOMEL'S METHOD. 151 

are indicated, and an entire abstinence, even from liquid nourish- 
ment, enforced upon the patient. When the disease is marked 
by bilious symptoms, a yellow fur on the tongue, a bitter taste, 
nausea, vomiting of bile, and constipation, the same general 
course is to be pursued as in its simple form. Chomel has not 
often resorted, even under these circumstances, to the use of 
emetics, since he has generally found that the symptoms just 
enumerated have subsided under the simple, hygienic treatment. 
He thinks, however, that in some of these cases, where the dis- 
ease comes on suddenly, and there is reason to suppose that the 
stomach may be oppressed by its contents, an early emetic would 
be useful. Chomel's mucous variety of typhoid fever is too indis- 
tinctly marked to make it necessary to notice the slight modifica- 
tions of treatment, which he thinks it may require. In the ataxic 
form of the disease, there are no uniform, rational indications. If 
it is attended with highly inflammatory symptoms, the active anti- 
phlogistic course is to be pursued; if it is attended with great 
debility, tonics and cordials are to be given. 

In the adynamic form of the disease, Chomel adopts a decided 
tonic and stimulant treatment, adapted in activity to the degree 
of prostration and debility. He speaks with great confidence of 
the propriety and necessity of this course, in these cases. Where 
the failure of muscular strength is extreme ; indicated by the dif- 
ficulty and languor of all the voluntary motions ; the feebleness of 
the voice ; the sinking of the features ; the fetor of the breath ; 
sighing and faintness on assuming the sitting posture ; smallness 
and weakness of the pulse ; and coolness or coldness of the sur- 
face ; it is necessary to administer, more or less freely, according 
to the number and gravity of these symptoms, tonics, aromatics, 
and cordials. Amongst these, the most important are cinchona, 
wine, camphor, and ether. Chomel prefers the cinchona, in the 
form of the extract, administered in an aromatic potion, to the 
amount of one or two ounces in the twenty-four hours. He also 
employs it in decoction or infusion, sweetened with lemon syrup. 
He doubts whether the sulphate of quinine is of equal efficacy as 
a tonic ; so that, notwithstanding the inconveniences frequently 
attending the administration of the extract, especially in. large 
quantities, he still prefers it to the former. At the same time that 
the cinchona is employed in this manner, he uses it, either in de- 
coction, or in extract, in the ibrm of enemata. 



152 TYPHOID FEVER. 

While the adynamic phenomena already enumerated are only 
moderate in degree, and before the necessity for the free use of 
cinchona has yet appeared, the lighter wines, such as those of 
Bordeaux, and Burgundy, may be given: when these phenomena 
are more strongly marked, the stronger wines, such as Madeira, 
Sherry, and Port, must be resorted to. These may be given to 
the patient in his drinks: or, as is best in the more grave cases, 
undiluted. The quantity to be administered must depend, ci 
course, upon the urgency of the symptoms calling for its use. A 
tablespoonful of one of the strong wines maybe given at intervals 
of from one to three or four hours. The effects of these remedies 
must be carefully watched ; and if they prodnce febrile heat, and 
restlessness, pain in the head, or any other obvious local disturb- 
ance, their use must be suspended, or modified. It will not often 
be either necessary or safe to resort to them in the early periods 
of the disease ; although such will sometimes be the case. It is 
commonly during the second or third week, or even later, that 
this tonic and stimulant medication is called for; and it is often a 
nice point, in the therapeutics of typhoid fever, to seize upon the 
exact period when it is required and will be borne. Ether is to 
be used when there is an urgent necessity for rapid and imme- 
diate stimulation; Chomel also occasionally combines it with the 
mixture of the extract of cinchona. Camphor he rarely uses, 
except as an ingredient in the tonic injections. In extreme cases, 
where there is a combination of the ataxic and adynamic elements, 
he recommends the use of musk, in large doses, by the mouth 
and by injection.^ He speaks more decidedly of the evils attend- 
ing the application of blisters, than of any benefits to be derived 
from them. 

The epistaxis will not often require any special attention. If 
it is at all copious, the application of a cold, astringent soluticn 
wUl generally be sufficient to arrest it. Sometimes, however, it is 
necessary to resort to mechanical compression, by plugging up the 
nostrils. To control the hemorrhage from the bowels, Chomel re- 
commends iced water for drink, in injections, and applied upon 
the abdomen ; lemonade, and the extract of rhatany. The forma- 
tion of ulcers should be guarded against, by avoiding constant 
pressure upon those points where they are most liable to occur ; 

* Gazette Meiicale de Paris, March, 1S35. 



TREATMENT.— CHOMEL'S METHOD. 153 

and when once formed, they should be protected from irritation, 
and properly dressed. Local inflammations, occurring in the 
early periods of the disease, or when the debility and prostration 
are not strongly marked, are to be met by local and general 
bleeding, adapted to the circumstances of the case. If the patient 
is in a condition not likely to tolerate these measures, dry cupping 
and sinapisms in the neighborhood of the inflammation, which is 
most commonly a pneumonia, may be substituted. When these 
complications take place, during the adynamic period, or in the 
adynamic form of the disease, they do not contra-indicate the use 
of stimulants and tonics. The local inflammation, under these 
circumstances, will be more surely relieved, or enabled to relieve 
itself, by a removal of the extreme general debility, through the 
agency of a tonic medication, than by the abstraction of blood. 
Perforation of the intestine is to be treated after the manner of 
Drs. Graves and Stokes of Dublin ; by entire abstinence from 
drinks and food ; absolute rest ; and large and repeated doses of 
opium. In the management of the patient, during convalescence, 
Chomel urges the importance of a mild diet, and the avoidance of 
fati2:ue ; and in cases where there seems to be some obstacle to the 
entire re-establishment of health, he recommends a removal from 
the city to the country. 

In 1831, at the suggestion of a young physician, who attended 
his clinical lectures at the Hotel Dieu, Chomel commenced the 
trial of chloride of soda, in the treatment of typhoid fever. He 
did not change, in any other respect, his system of management, 
but superadded the use of this remedy to the rational plan of treat- 
ment which has just been described. He administered the chlo- 
ride in a sweetened solution of gum Arabic, containing from one 
grain to one grain and a half, to the ounce. Of this solution, his 
patients generally took from fifty to ninety ounces, in the twenty- 
four hours. Injections of the same solution were given morning 
and night; the body of the patient was freely washed, several 
times a day, with a solution of the chloride in water; poultices 
moistened with it w^ere applied to the abdomen; the bed clothing 
was sprinkled with it; and vessels containing it were placed 
under the bed. In order to test, as nearly as possible, the value 
of this specific medication, it was mostly confined to well-defined 
cases, at least of sufficient severity to be attended with some dan- 
ger ; and in which it could be applied at the beginning, or early 



154 TYPHOID FEVER. 

in the disease. The results of this plan, in the hands of Chomel, 
from 1831 to 1S34, the year in which his work on tvphoid fever 
was published, were rarious and not veiT decisive. In that work, 
however, he expresses himself, at the close of his remarks upon 
this subject, in the following terms : "Finally, although the re- 
sults of this treatment have been very different in different years, 
it has stiU been attended with more success, than any other. Se- 
veral distinsruished practitioners have informed us, that they have 
arrived at the same conclusion. We shall continue, then, our 
trials with a mode of treatment, which, combined with the rational 
method, has thus far given ns, notwithstanding its failures, more 
satisfactorv results than any other." Subsequent to this, how- 
ever, in 1835, with a frankness, a conscientiousness, a single- 
minded resrard for the truth, which it is beautiful to witness, he 
says, '• The hopes, which our first trials with the chloride had 
permitted us to conceive, have not been realized. The results, 
which have thus far been obtained, are not sufficiently encourag- 
ing to justify us in the expectation of continuing our trials with 
much chance of success."^ 



ARTICLE IT. 

LOOS'S METHOD. 

Louis, in the second edition of his Researches on Typhoid 
Fever, published, in 1841, seems somewhat undecided in his 
opinion npon the therapeutics of the disease.^ He hesitates be- 
tween the rational method, which he had a-enerallv followed, and 
the purgative plan adopted by De Larroque. Putting the latter 
out of consideration, for the present, Loms, after a verv careftil 
and thorough examination and analvsis of the effects of remedies, 
finally fixed upon the following general plan of treatment, as the 
best that could be pursued, in the present state of our knowledge 
upon this subject. 

Early in the disease, and at any rate within the first ten or 
twelve days, he' resorts to general blood-letting, its extent and 
repetition to be proportionate to the strength and vigor of the pa- 
tient, and the severity of the disease. If the case is mild, or of 

1 La Lance-e Frarpaise. AngTist, 1535. * 

* Louis on TTjhcii Ferer. toL iL p. 37&, «f «g^ 2d ed. 



TREATMENT.— LOUIS'S METHOD. 155 

moderate severity, and the constitution of the patient not very 
robust, a single bleeding of twelve ounces will be sufficient ; in 
other cases of greater severity, and where the constitution is sound 
and vigorous, the bleeding should be somewhat more copious, and 
repeated once or twice. Louis is satisfied, that this remedy, 
within these limits, is generally useful in shortening, to the extent 
of a few days, the average duration ; in diminishing the gravity, 
and of course in lessening somewhat the mortality, of the disease. 
After the fifteenth day, in severe cases, and at an earlier period 
in mild ones, where there is but moderate febrile excitement, 
blood-letting should not be practised. Under these circumstances 
the operation does no good, and retards instead of hastening the 
period of convalescence. Louis has not found the immediate 
eflfects of blood-letting, either upon the general severity of the dis- 
ease, or upon any of the single symptoms, to be very marked or 
obvious. In some cases, the operation is followed, either at once, 
or in the course of twenty-four hours, by an amelioration of one or 
more of the most urgent symptoms ; in some cases, on the other 
hand, it is followed by their aggravation; and furthermore, these 
changes in the severity of the symptoms are such as frequently 
occur, where blood-letting has not been resorted to, and where, 
indeed, no active medication has been used. 

This measure is to be aided by suitable drinks, emollient ene- 
mata, and cool, fresh air. The drinks should consist of sweetened 
gum water, or of this in combination with artificial Seltzer water, 
in order to obtain the effects of the carbonic acid gas. They 
should be given in large quantities, as freely as the patient may 
desire. Mucilaginous enemata are to be given once a day, during 
the early period of the disease; and, subsequently, when the 
diarrhoea is troublesome, two or three times a day. If, notwith- 
standing their use, the discharges from the bowels continue to be 
frequent, and debilitating, a small injection, containing a few 
drops of laudanum, should be substituted. 

Tonics are considered by Louis not only very useful but very 
necessary, under certain circumstances. When the general fe- 
brile excitement has subsided; when the prostration of strength is 
extreme ; when the pulse is only moderately accelerated, or not 
at all ; w^hen there is slight diarrhoea, and little or no tympanites ; 
they should be at onc^ and freely resorted to. Louis prefers the 



156 TYPHOID FEVER. 

sulphate of quinine to any other article, given in an aromatic or 
mucilaginous draught, in doses of from eight to twenty grains. 
He gives the patient, at the same time, a sweetened infusion of 
cinchona for drink; and, if there is diarrhoea, he makes use of 
tonic and astringent injections. 

Louis dismisses blisters from his plan of treatment, with strong 
and unqualified condemnation. He says there is no evidence, 
that they are of any benefit, and that, not unfrequently, they add 
to the gravity, the inconveniences, and danger of the disease. 
For the last ten or twelve years, he has abandoned them entirely. 
He recommends opium, after the method of Graves and Stokes, 
in cases of perforation of the intestine, though in smaller doses. 
He reports a case, probably of this accident, which occurred at 
the Hotel Dieu in 1840, and which was cured by this method. 
Opium, he thinks, is also of use in allaying some of the nervous 
symptoms ; such as twitching of the tendons and slight delirium, 
when the febrile excitement is not very high. \Mien the delirium 
is violent, he has seen little or no benefit from the use of leeches, 
or the application of ice to the head; but he recommends, in this 
case, if the face is flushed, even if the disease has reached its 
twelfth or fifteenth day, and even if the patient has already been 
twice bled, another moderate bleeding. When the meteoiism is 
extreme, he thinks it may sometimes be diminished by the admi- 
nistration of enemata, consisting^ of masrnesia in an infusion of 
flaxseed. In grave cases, the condition of the bladder should be 
carefully watched from day to day, and retention of urine guarded 
against. It is unnecessary to repeat his observations upon the 
importance of rest, cleanliness, and free ventilation, during the 
progress of the disease ; and of light diet and the avoidance of 
fatigue during convalescence. 

In concluding this subject, Louis makes use of the following 
words: — "It results from all that precedes, upon the effects of 
the principal therapeutic agents at present employed in the treat- 
ment of typhoid fever, that these agents possess a favorable though 
limited influence upon the march and termination of the disease ; 
and that an impartial examination of facts points out, with a 
good degree of precision, the best method of employing the three 
principal means, which experience has placed in our hands; to 
wit, blood-letting, evacuants, and tonics. Furthermore, the limited 
degree of success, which has thus far been obtained, ought not 



TREATMENT.— BOUILLAUD'S METHOD. 157 

to discourage the friends of science, nor prevent them from 
hoping, that a more appropriate and successful treatment of this 
disease ^vill yet be discovered. Who could have foreseen the 
effects of opium, of cinchona, or the preservative power of the 
vaccine virus.'* \¥hat accident and observation have hitherto 
done they are still able to do, without doubt they still will do ; 
and therapeutics, like the other parts of science, ought to hope 
and to expect every thing from observation." 

ARTICLE V. 



Some fifteen or eighteen years ago, Bouillaud introduced a mode 
of practice, in the treatment of all acute diseases, and amongst 
them of typhoid fever, which he claims to be of his own discovery, 
and which he claims also to have been attended with extraordi- 
nary success. This mode consists in copious and frequently re- 
peated abstractions of blood, and in the application of leeches, or 
of scarified cups, in the intervals.^ The number of his bleedings 
varies from one to five or six, of from twelve to sixteen ounces 
each ; and nearly or quite an equal quantity of blood is taken from 
the patient by means of leeches or cups. This lavish waste of 
the vital fluid is not confined to the earliest period of the disease, 
since many of the patients, who are subjected to it, are not re- 
ceived into the hospital until the second wTek of the fever. The 
average day, indeed, is as late as from the ninth to the twelfth. 
This method he calls that of bleeding coup sur coup, blow upon 
blow% or dash upon dash, or again and again. He claims to have 
reduced the practice of blood-letting, in acute diseases, to an esta- 
blished formula. In connection wdth this subject, he also an- 
nounces, in loud and confident tones, that success, or cure, is the 
law; foilure, or death, the exception. He claims for his new 
method an almost infinite degree of superiority over those generally 
in use; and that the actual, average, mortality, under it, is less 
than half as great, as under the old and generally adopted plans. 

The bold and arrogant terms in w^hich these high pretensions 
w^ere put forth, the offensive freedom of Bouillaud's remarks upon 

' Essai sur la Pliilosophie Medicale, etc. Par J. Bouillaud, p. 412, et seq. Brux- 
elles, 1S36. 



158 TYPHOID FEVER. 

the practice of his cotemporaries, to say nothing of the import- 
ance of the subject, and the interests of humanity and science, 
soon led to a thorough examination, and a discussion, generally 
warm and sometimes intemperate, of his claims. It is not my 
intention to enter into a history of these proceedings. It is quite 
sufficient for my purpose to say, that his statistical tables were 
rectified, his mistaken diagnoses were corrected, and the positive 
results of his practice shown to be in no degree more favorable 
than those of other physicians ; probably less so. It ought to be 
said, however, before dismissing the subject, that if Bouillaud has 
failed to establish the superiority of free and repeated bleeding, in 
the treatment of typhoid fever, he seems, at least, to have shown, 
that the practice is borne in this disease, with a greater degree of 
impunity, and is attended with less danger, than had generally 
been supposed possible. 



ARTICLE VI. 



There is still another exclusive mode of treatment, very unlike 
that of Bouillaud, which has been pretty extensively followed, 
within the last ten or twelve years, in the hospitals of Paris. I mean 
that by evacuants, and principally by purgatives. The fifteen or 
twenty years' reign of the Broussaisian doctrine of fevers, in Paris, 
had almost entirely banished emetics and purgatives from the 
treatment of these diseases. Their use was formally and abso- 
lutely proscribed. It was murderous and incendiary to give 
either one or the other. After this medico-doctrinal dynasty had 
had its day and gone by, therapeutics became gradually more 
eclectic and less exclusive. Different modes of practice were 
adopted by different physicians, in the same disease ; and it could 
hardly fail to be discovered, that the fears which had so univer- 
sally prevailed, founded upon theoretical considerations, of the 
injurious effects of purgatives, were either without foundation, or 
very much exaggerated. Lerminier, of Paris, and Bretonneau, of 
Tours, had occasionally made use of purgatives in the treatment 
of typhoid fever ; but M. De Larroque, a physician of the Necker 
Hospital, was the first to adopt the evacuant, or emetico-cathartic 
plan, as a general and almost exclusive mode of treatment, in this 



TREATMENT.— MISCELLANEOUS. 159 

disease. He romraenced his trial of this method in 1831, since 
\vhich time it has been more or less extensively followed by Pie- 
dagnel at the Hotel Dieu, Andral, at La Charite, Louis, at La 
Pitie, and by others. The plan adopted by De Larroque is the 
following: — He usually commences his treatment by the adminis- 
tration of an active antimonial emetic; and this is to be repeated 
until free vomiting is procured. The operation of the emetic is 
to be immediately followed by the use of purgatives, without much 
regard to the state of the bowels, the condition of the patient, or the 
period of the disease ; and these are to he continued regularly up to 
the time of convalescence. His principal articles are Seidlitz 
water, castor oil, and calomel. To these remedies, he adds emol- 
lient poultices to the abdomen, when there is pain in this region; 
mucilaginous injections, morning and night; acidulated drinks ; 
and when the febrile excitement subsides, light tonics. Louis, in 
the second edition of his Researches, expresses himself pretty 
strongly in favor of the purgative treatment. He himself made 
use mostly of Seidlitz water, and he thinks that his success with 
this method was greater, than with his former practice. 

Barthez and Rilliet are opposed to the purgative plan of treat- 
ment in children ; they think it increases the danger of enteritis. 

ARTICLE Vn. 

MISCELLANEOUS. 

In addition to the accounts which have been given of the fore- 
going systematic methods of treatment, it maybe well to mention, 
in conclusion, some few individual remedies, and their applica- 
tion, which have been recommended by different practitioners. 
M. Barthez and M. Fouquier, amongst the French, and Drs. Dob- 
ler and Skoda amongst the Germans, have made use of alum; 
supposing that it might act directly in retarding the progress and 
in diminishing the severity of the intestinal lesion. I am not 
aware that there is yet any satisfactory proof of its utility. Dr. 
Gerhard thinks, that, in mild cases, gentle purgatives, such as a 
few grains of blue pill, followed by castor oil or Seidlitz powder, 
should alw^ays be given at first, for two or three days ; and that, 
whenever constipation is present, the repetition of the laxative is 
useful. If the dizziness and headache are troublesome, he says 



160 TYPHOID FEVER. 

that they may be removed or greatly relieved, by cupping, by a 
mustard pediluvium, or by a blister to the nucha. From the latter 
application, when properly timed, that is, after the active febrile 
excitement has subsided, Dr. Gerhard has never known any injury 
to result, and he has generally found it to mitigate the severity of 
moderate cerebral symptoms. In both severe and mild cases, 
towards the decline of the disease ; that is, about the end of the 
second week, if it be severe, and a little earlier, if it be mild, he 
makes use of small doses of calomel, or of blue pill, combined 
with ipecacuanha, and with a minute quantity of opium, if the 
diarrhoea is troublesome. One or two discharges from the bowels, 
daily, he thinks, are of service in all stages of the disease.^ In 
cases of hemorrhage from the bowels, I always make free use of 
opium and sugar of lead, and generally with entire success. 

I have already spoken of the unsettled and discordant state of 
the professional mind in regard to the therapeutics of typhoid 
fever. It would be no difficult matter to multiply and strengthen 
the proofs of this truth, already sufficiently shown by the foregoing 
details. This, however, would be but an unprofitable labor; in 
the present state of our knowledge, of no practical value. Under 
the circumstances in which we are placed, amidst the claims and 
pretensions of confficting opinions, it seems to me, that we are 
not now justified in the use of any ultra, or exclusive, system of 
treatment; like that, for instance, of Bouillaud, or De Larroque. 
For the present, our management of the disease must be eclectic, 
and rational; not exclusive, and specific. In its early stages, 
unless in cases where there may be special contra-indications, it 
seems to be generally conceded, that a moderate antiphlogistic 
course is the best that can be adopted; and that active emetico- 
cathartics, if used at all, ought to be used at this same early 
period. In the subsequent progress of the disease, a mild, altera- 
tive and rational plan, keeping the bowels moderately loose by 
laxatives, w^hen this is necessary, and meeting particular symp- 
toms with such remedies as experience has shown to be most 
suitable, would appear to be most appropriate and successful. 
After the first few days, in cases of moderate or average severity, 
with no special or urgent indication, it is quite clear, I think, that 
all treatment, in any way decidedly active or perturb ating, is to 

1 Medical Examiner, vol. iv. pp. 150, 151. 



TREATMENT.— MISCELLANEOUS. 161 

be avoided. The tendency of the disease, in all such cases, is 
towards a natural termination in health ; and there is no evidence, 
that the dangerous complications, which are liable to occur, can 
be prevented by any active interference. In all grave cases, and 
especially when stupor or delirium is present, the region of the 
bladder should be carefully examined, every day, in order to 
guard against the distention of the organ by urine. I may remark, 
in this connection, notwithstanding what has been said, that care- 
lessness, or indifference, in the management of the disease, grow- 
ing out of the unsettled state of opinion in relation to its treatment, 
and of the limited control, which we possess over it, would be as 
criminal a dereliction of duty, as it w-ould be unbecoming in a 
cultivator of the science, and a practitioner of the art of medicine.^ 
We may hope, that our treatment of this disease will yet become 
more successful, and more uniform; more exact in its application, 
and more positive in its results. Many " ministers and interpreters 
of nature," faithful to their high vocation, and competent to its 
duties, are zealously and patiently occupied in endeavoring to 
accomplish this end. Guided by a sound philosophy; relying 
upon the one great means of ascertaining the properties and rela- 
tions of all forms of matter, inorganic and organic, that of obser- 
vation, they or their successors may yet find, by persevering 
experiment, or fortunate discovery, methods of modifying the 
living organization, and of correcting its disordered actions, 
which shall give us a much greater control over the disease, than 
we are now able to exert. 

1 It is both interesting and gratifying to see the good sense and sound judgment 
of some of the continental practitioners of the last century, in the management of 
this disease. Burserius, after having given a most excellent description of the 
fever, recommends moderate bleeding where there is much excitement, a mild 
emetic at the commencement, diluent drinks, and then says: — "But a simple plan 
of cure, if it is to be recommended in any case, is certainly to be adopted in the 
present. For the less the operations of nature are disturbed by art, the milder and 
safer the remedies we employ are, the more successfully do we restore the patient's 
health." — Institutions Pract. Med., vol. i. p. 506. And again, he adds: "The proper 
regulation of the diet alone, and time, perform great part of the cure. The poorer 
people, generally content with patience, and proper attention to the regulation of 
the diet, despising all kinds of dntgs, recover more certainly." — Ibid. 530. 

11 



162 



CHAPTER XI. 

DEFINITION. 

We may, provisionally at least, adopt the following definition 
of the disease, the natural history of which has now been given. 

Typhoid fever is an acute affection; occurring, most frequently, 
between the ages of fifteen and thirty years, sufficiently often pre- 
vious to the former period, and but rarely after the fortieth year 
of life; attacking, at least in cities and amongst adults, in a large 
majority of instances, persons who are recent residents; occasion- 
ally, and under certain conditions, capable of transmission from 
one indi\adual to another ; rarely occurring twice in the same 
person ; more common in certain countries, than in others, but 
not confined, so far as is known, to any geographical localities, or 
regions ; prevailing at all seasons of the year, and in all climates, 
but more common in the autumn than at other periods, and in 
temperate and northern than in southern and hot latitudes ; some- 
times sudden, and sometimes gradual, in its access; attended, at 
its commencement, with chills or rigors, not commonly very 
severe, and usually repeated, at uncertain intervals, for the first 
few days ; then, with more or less feverish heat of the skin ; gene- 
rally, with increased quickness of the pulse ; somewhat accelerated 
respiration; slight, dry, cough; an extensive sonorous, or sibilant, 
rhonchus ; with pain in the head, back, and limbs ; loss of the 
vigor, and, in grave cases, perversion of the faculties, of the mind ; 
dull expression of the countenance; more or less somnolence, or 
watchfulness ; giddiness, or dizziness ; ringing, roaring, or buzzing, 
in the ears ; occasional epistaxis ; great loss of muscular strength ; 
in grave cases, with spasmodic twitchings of the muscles, espe- 
cially those of the forearms and hands ; with entire loss of appetite, 
and with thirst ; sometimes, with nearly a natural appearance of 
the tongue, and at others, with a red, dark, dry, glutinous, cracked, 
trembling state of this organ; sordes upon the teeth, and gums; 
occasional nausea, and vomiting; frequent diarrhoea; abdominal 



DEFINITION. 163 

pains, and tenderness; these latter not unfrequently most marked 
in the right iliac region; dullness on percussion over the spleen; 
meteoric distention, or rigidity, of the abdomen; the skin, particu- 
larly of the front part of the body, being usually the seat, in the 
course of the second and third weeks of the disease, of a peculiar 
eruption, not commonly abundant, consisting of small, circular, 
or oval, spots, of a bright rose color, slightly elevated above the 
surrounding surface, and readily disappearing under pressure; 
the blood, when drawn from the body, having its proportion of 
fibrine diminished, in a degree closely corresponding to the gravity 
of the affection: — which symptoms differ, very widely, in their 
duration, in their march, in their severity, and in their combina- 
tions, in different cases ; no one of which is invariably met with, 
and several of which are frequently wanting; but enough of which 
are almost always present to characterize the disease : — which 
symptoms, furthermore, may either gradually diminish in severity, 
and finally disappear, between the twelfth and the thirtieth day of 
the disease; or may increase in severity, and terminate in death, 
between the seventh and the fortieth day from their access : — the 
bodies of patients exhibiting, on examination after death, in only 
a certain proportion of cases, various pathological changes in the 
brain, heart, lungs, stomach, and liver; but, in most cases, en- 
largement, or softening, or both, of the spleen; and, in all cases, 
thickening, or redness, or a morbid transformation, or ulceration, 
or all these changes, of the elliptical plates of the ileum ; with 
enlargement, redness and softening of the mesenteric glands, cor- 
responding, in their position, to the altered intestinal follicles: — 
which disease, thus characterized and defined, differs essentially 
from all others, in its causes, in its symptoms, in its lesions; and 
is, in the present state of our knowledge, only to a limited extent 
under the influence or control of art. 



164 



CHAPTER XII. 

BIBLIOGRAPHY. 

The bibliography of typhoid fever, as a distinct and specific 
disease, may properly enough be said to have commenced with 
the publication of Louisas Researches, in 1829. I do not forget 
the earlier works of Roederer and Wagler, in Germany ; and of 
Prost, Petit and Serres, and Bretonneau, in France, on the same 
subject, nor the description of Huxham in England, and of Nathan 
Smith in America ; but these publications, compared with that of 
Louis, were fragmentary and incomplete. Other continental writers 
have also given very good general descriptions of the disease, 
under the names of typhus, adynamic, ataxic fever, and so on. 
These descriptions are now of but little value, for the reason that 
no clear distinction was made between true typhus, and typhoid 
fever. It indeed remains to the present moment a question un- 
decided, whether the camp, the jail, and the typhus fevers of the 
continent of Europe, previous to the thorough study of typhoid 
fever, were identical with this disease, or constituted a distinct 
and different species. My own opinion is, as I have already 
stated, that both parties are partly right and partly wrong. It is 
probable that both typhoid and true typhus fever made up these 
diseases ; and it is quite impossible to determine now, in many 
cases, to which of the two any particular epidemic belonged. 

Besides the few but very important works which are hereafter 
briefly mentioned, Andral, Bouillaud, Cruveilhier, and others 
amongst the French; and Schonlein, Skoda, Rokitanski and others 
amongst the Germans, have written, more or less extensively and 
systematically upon this disease. Several important papers have 
also been published in the French Medical Journals. The British 
have done but little, for reasons which need not be repeated. 

Medecine eclairee par V ohservation et Vouverture des corps. 
Par P. A. Prost. Paris, 1804. In connection with the history of 
the researches in relation to typhoid fever, this is a very remarka- 



BIBLIOGRAPHY.— PROST. 165 

ble book. Prost may be fairly regarded as one of the far fore- 
runners of Louis. He seems to have devoted himself, for a con- 
siderable period of time, with great assiduity and faithfulness, and 
almost exclusively, to the observatioii of disease, in its most ex- 
tended sense, in the large hospitals of Paris. Before publishing 
his book, he had made more than four hundred autopsies, many 
of them requiring an entire day, and none less than several hours. 
One of the first fruits of his arduous and conscientious study of 
nature Avas the discovery, that in the ataxic fevers of Paris, there 
always existed inflammation, with or without ulceration, of the 
mucous membrane of the intestines. Bouillaud, in speaking of 
Prost's work, says, — " This fine commencement of a revolution, 
which, ten years later, was destined to shake the temple of medi- 
cine to its deepest foundations, w^as suffered to pass almost un- 
noticed. Truly, Prost might have said of his epoch, as Tacitus 
said of another, — * nostra oetas oblivia suorum.'* " 

There is a curious fact in medical literature, connected with 
this portion of the history of fever. Prost's book, as Grisolle says, 
fell, still born, from the press. Almost the only one of his co- 
temporaries, who took any special notice of it, was Broussais ; — 
and a singular notice this w^as, coming, as it did, from a man, 
whose highest title to glory, — subsequently claimed for him, both 
by his disciples and by himself, — consisted in a fuller develop- 
ment of this very doctrine of Prost. Broussais, in the first edition 
of his History of Chronic Inflammations, after citing the opinion of 
Prost, relative to the influence of inflammation of the digestive 
mucous membrane, in the production of ataxic fever, says, — " I 
have too often found this membrane in good condition after the 
most malignant typhus ; I have seen too many patients improved 
by the employment of the most energetic stimulants, to share the 
opinion of this physician on the cause of ataxic fever." And 
still the truculent and unscrupulous reformer, after having thus 
summarily rejected, as worthless, the materials which had been 
laboriously quarried from the great primary formation of nature, 
did not hesitate to make use of them, as corner-stones for the 
temple, which he himself strove to build. 

Prost's work is in two volumes, and the greater part of it is 
made up of short histories of disease, with an account of the 
several organs after death ; — only a small proportion of these 



166 TYPHOID FEVER. 

being cases of fever. The preliminary observations are to a great 
extent speculative and hypothetical. 

A Practical Essay on Typhous Fever. By JYathan Smith, M. D. 
The author of this modest^ and unpretending essay, was an ex- 
tensive and distinguished teacher and practitioner of medicine 
and surgery, throughout many portions of the New England states, 
during the first quarter of the present century. He was a remark- 
able man; and his name stands worthily and fitly by the side of 
those of Huxham, Pringle, and Blane. My opinion of the value 
of the essay above mentioned has been already sufficiently attested, 
by the incorporation into my book of a large portion of its matter. 
To an American practitioner, it is worth infinitely more than all the 
modern English treatises on fever put together ; for this simple rea- 
son, if for no other, that it deals with the form of disease with which 
he is familiar, — which the English treatises do not do. Nathan 
Smith was a shrewd, clear-headed, patient, and careful student 
of nature, — his vision undazzled and his judgment never perverted 
by fanciful speculations; and the labor of my book will not be 
wholly lost if it succeeds in some degree in calling back the at- 
tention of my countrymen to his neglected and almost forgotten 
pages. The essay was published in 1824. 

Anatomical, Pathological, and Therapeutical Researches upon the 
disease known under the names of Gastr o- Enteritis ; Putrid, Adyna- 
mic, Ataxic, and Typhoid Fever. By P. Ch. A. Louis, 2 v. Paris, 
1829. This is the great work of Louis, to which reference has been 
so constantly made throughout the preceding history. An American 
edition was published, from a translation by Henry J. Bowditch, 
M. D., in 1836. A second French edition was published in 1841. 
The work, at the time of its first appearance, was entirely without 
a parallel, if we except the Researches on Phthisis, by the same 
writer. These works of Louis have become the established models 
for all similar undertakings ; they are the standards by which all 
analogous labors are to be tried. Here and there, a single indi- 
vidual has attempted to depreciate their value and underrate their 
importance, — a value and an importance which every successive 
year since their appearance has only served to strengthen and 
confirm. Like new planets added to a solar system, they have 
quietly but irresistibly wheeled into their orbits, from which they 
are henceforth no more to be jostled, than the planets are from 
theirs. 



BIBLIOGRAPHY. 167 

Legons de Clinique Medicale, etc. Par A. F. Chomel. Fieiire 
Typhoide. Paris, 1834, pp. 548. Next to the great work of 
Louis, this is, perhaps, the most valuable original treatise on 
typhoid fever that has been published. It is not so methodical in 
its plan and arrangement as it might have been, and the anato- 
mical details are somewhat prolix, extending as they do to nearly 
two hundred and filly pages ; still, as I have just said, the work is 
second only to one in value. It is rich in solid material, and is 
marked throughout by the clearness, good sense, and sound phi- 
losophy of its distinguished author. 

A Report, founded on the Cases of Typhoid Fever, or the com- 
mon Continued Fever of A'^ew England, which occurred in the 
Massachusetts General Hospital, from the opening of that Institu- 
tion in September, 1821, to the end q/*1835. By^ James Jackson, 
M.D., pp. 93. 1838. There is no need of my speaking at any 
length of this Report; the preceding pages bear ample and con- 
clusive evidence of the richness and value of its materials. It 
consists, mostly, of a careful and accurate numerical analysis of 
three hundred and three cases of typhoid fever, treated in the 
Massachusetts General Hospital. It is altogether the most im- 
portant contribution which has been made to the history of the 
continued fever of New England, and it is in every way worthy 
its distinguished author, — the elder Louis of the New World. 

Remarks on the Pathology of the Typhoid Fever of JYew Eng- 
land; as exhibited in its Physical Signs, and its Anatomical Ap- 
pearances. By Enoch Hale, M. D., 1839, pp. 68. This paper, 
like the Report of Dr. Jackson, is published amongst the Commu- 
nications of the Massachusetts Medical Society. It is a very ex- 
cellent and sensible paper; and it is particularly valuable for its 
minute and careful description of some of the more characteristic 
physical signs of typhoid fever, — such as the meteorism, and the 
rose spots ; and of the intestinal lesions ; and further for its full 
and clear statement of the differences between typhoid and typhus 
fever. 

Traite de PEnterite Folliculeuse, — Fievre Typhoide. Par C, 
P. Forget. Pans, 1841, pp. 846. This is a work of very large 
promise, and of very moderate performance. It is a full and sys- 
tematic monograph of more than eight hundred solid pages, in 
which tKe author has contrived neither to give us a compact and 



168 TYPHOID FEVER. 

clear summary of the researches of others, nor to add any import- 
ant knowledge of his own. As Sir James Mackintosh said, on 
another occasion, it is one of the most unnecessary books in the 
world. One of its leading objects is to vindicate the strictly local 
and inflammatory nature of typhoid fever, and the consequent, 
rational, antiphlogistic treatment. 



PAKT SECOND. 

THE 

HISTORY, DIAGNOSIS, AND TREATMENT 

OF 

TYPHUS FEVER. 



PART II. 
TYPHUS FEVER 



CHAPTER I. 

PRELIMINARY MATTERS. 
ARTICLE I. 

INTRODUCTORY. 

I NOW proceed to the description of Typhus Fever, The natu- 
ral history, which I shall be able to give of this disease, will be 
somewhat less complete, than that which I have already given of 
typhoid fever. The reason of this is twofold : in the first place, 
I have seen much less of the disease myself; and in the second 
place, but few entire and elaborate histories of the disease have 
been published. We have many excellent general descriptions 
of it, especially as it has shown itself in certain localities, and 
during certain epidemic periods; but we have had no thorough 
and detailed histories of its symptomatology and lesions; like 
those which Louis, Chomel, and others have furnished us of 
typhoid fever. To these remarks, it may be added, that the 
diagnosis of typhus fever, by most of the observers upon whose 
records we must depend for our materials, is much less accurate 
and positive, than that of typhoid fever is, as this disease shows 
itself in New England, and in France. Typhus fever is more 
frequently confounded and mixed up with other diseases, by its 
best historians, than typhoid fever is; and in this way, another 
element of incompleteness and confusion is introduced into its 
history. 

The materials for the following description will be derived 
mostly from British physicians, especially those of Ireland, and 
Scotland; and from Dr. Gerhard of Philadelphia. The accounts 



172 TYPHUS FEVER. 

of typhus fever, which have been published, from time to time, and 
mostly in the form of Hospital Reports, bv the Scotch, and Irish 
practitioners, constitute our richest and most authentic sources of 
information in the studv of this disease. This remark is especially 
applicable to the Hospital Reports of Dublin, made subsequent 
to the vear 1812; by Edward Percival, John O'Brien, F. Baker, 
William Pickels, John Cheyne, and others. I know nothing ot 
a like character in the English language superior to the Hospital 
Reports of John Cheyne : and one of the most valuable histories 
of the disease now under consideration, which has ever been pub- 
lished, is to be found in the account given by Dr. Barker, and 
Dr. Cheyne, of the great epidemic of typhus fever, which overran 
Ireland, during the years 1817, 1818, and 1819. One reason for 
this reliance, which I am disposed to place upon the observations 
of Irish, and Scotch writers, rests upon the belief, the grounds of 
which will be fully stated hereafter, that true ti/phus fever is mo: r 
exclusively the prevailing fever in Ireland, and in the northern 
portions of the British empire, than it is in the middle and south- 
ern regions of England. Dr. Gerhard has published, in the 
American Journal of ^ledical Sciences, a very valuable historv 
of an epidemic typhus fever, which prerailed in Philadelphia, 
durins: the spring and summer of 1S36 ; and which was carefullv 
studied by himself, and Dr. Pennock. I am aware of the danger 
of trusting to the phenomena presented by any single epidemic, 
in making up the history of a disease, and I do not intend, in the 
present instance, to be guilty of this fault. I look upon the pa- 
pers, published by Dr. Gerhard, as of inestimable value; but i: 
is only by a careful examination of many histories of typhus 
fever, and by a methodical arrangement of the materials which 
they may furnish, that I can hope to make out even a tolerably 
complete and satisfactory description of the disease. 

I shall follow, as far as this can conveniently be done, the same 
general plan, in the disposition of the several subjects of inquiry 
and description, as has already been adopted, in the foregoing 
history of typhoid fever. 



PRELIMINARY MATTERS. 173 

ARTICLE II. 

NAMES OF THE DISEASE. 

The term typhus, from the loose manner in which it has been 
used, and the various morbid conditions to which it has been ap- 
plied, has become somewhat indefinite in its signification. It is 
only important for me to say here, that I mean by it an idiopathic, 
contagious fever, prevailing, generally, amongst crowded popula- 
tions, and in badly ventilated localities, and not marked by any 
constant lesion of the solids. The other most common names by 
which it has been known are the following, to wit, — Hospital 
Fever; Jail Fever; Camp Fever; Malignant Fever; Putrid 
Fever; Petechial Fever; and Contagious Typhus. It should be 
added that these latter terms have not been invariably and exclu- 
sively confined to true typhus ; they have been sometimes applied 
to typhoid fever. 



174 



CHAPTER 11. 

SY^IPTO^IS. 
ARTICLE I. 

MODE OF ACCESS. 

Typhus fever is sometimes sudden, and sometimes gradual, in 
its access. I am unable to state, with any degree of certainty, 
the proportion between these classes of cases. In a large majori- 
ty^, however, the formal accession of the fever seems to be pre- 
ceded by several days of vaguely defined ill health, as is the case, 
also, with typhoid fever. In six or eight cases, reported by Dr. 
Gerhard, the patients complained, for a period of from three to 
seven or eight days, of various uncomfortable feelings; such as 
languor, loss of appetite, soreness of the muscles, sleeplessness, 
wandering pains in different parts of the body, and so on. In 
the other two cases, the disease came on suddenly. Dr. O'Brien 
says, that these premonitory symptoms continue generally for a 
few days, but sometimes for a week or two. Amongst these 
symptoms, he enumerates lassitude, and fatigue, on the least 
exertion; dullness of the eyes; sallowness, and dejected expres- 
sion of the face; heavy, dull pain in the head; slight nausea ; 
anxiety, without any apparent cause ; slight chills, frequently 
repeated, especially towards night, and imperfect, disturbed 
sleep. ^ Dr. Pickels speaks of the disease as being nearly always 
preceded by trembling and nausea.^ Dr. John Cheyne, in his 
description of the fever of the spring and summer of 1818, as it 
showed itself at the Hardwicke Hospital, Dublin, says: — " Some 
patients felt an unaccountable dejection of spirits, for several 
days before seizure ; some continued at work or labor, for several 
days after their illness began in the shape of a headache, which 
frequently intermitted ; in a few, the disease began with intense 

' Trans, of Pays, of Ireland, vol. i. p. 410. 2 ibid., voL iii. p. 193. 



SYMPTOMS —CHILLS.— SKIN. 175 

headache without rigor; the patients being, as they said, at once 
knocked down."^ 

Many writers, who have seen much of the disease, mention 
cases, in which persons in full health, while standing by the bed 
of the sick, and breathing the infected atmosphere from the body 
and bed of the patient, have been instantaneously seized with 
nausea, giddiness, faintness, and so on, and these symptoms have 
been immediately followed by the gravest form of the fever. These 
sudden seizures are more common in typhus, than they are in 
typhoid fever; indeed, I do not know that they are ever seen in 
the latter disease. 

ARTICLE II. 

FEBRILE SYMPTOMS. 

Sec. I. — Chills. I do not know that there is anything peculiar, 
or characteristic, in the initiatory chill of typhus. Many writers 
speak of it very indefinitely, or not at all. Sometimes, it is of 
some severity, and w^ell marked; but in many cases it seems to 
consist merely of a sense of chilliness, felt over the whole body, 
or especially, perhaps, along the back, and continuing, not un- 
frequently, for two or three days. 

Sec. II. — Heat and State of the Skin. After the disease is fully 
formed, the surface of the body becomes preternaturally hot. The 
heat of the skin is peculiar and pungent, constituting what has 
been called ^'calor mordicansy Dr. Gerhard says, that this 
burning heat of the skin was so remarkable, in the Philadelphia 
epidemic of 1836, that the resident physicians, and others, would 
frequently diagnosticate the disease, from this symptom alone. 
This morbid heat is generally accompanied by dryness of the 
skin. It is increased towards night, forming a well marked even- 
ing exacerbation. Dr. Edward Percival observes, that the strongly 
marked exacerbation occurs more frequently in the first, than in 
the second or third w^eek, of fever. During the spring and sum- 
mer of 1817, the temperature of the surface on the day of admis- 
sion to the Hardwicke Fever Hospital, Dublin, was ascertained 
by the thermometer, in two hundred and fifty cases. It ranged 

' Dub. Hos. Rep,, vol, ii. p. 4. 



176 TYPHUS FEVER. 

from 97 to 100 deg. Fah. inclusiTe, in eighty-three cases; from 
101 to 106 deg. Fah. inclusive, in one hundred and sixty-three 
cases; and from 107 to 109 deg. Fah. inclusive, in four cases. ^ 
During the winter and spring of 1818, a similar examination was 
made of ninety-nine cases, with similar results. The temperature 
ranged from 95 to 100 deg. Fah. inclusive, in twelve cases; and 
from 101 to 106 deg. Fah. inclusive, in seventy cases; and from 
107 to 109 deg. Fah., in seventeen cases. Towards the termi- 
nation of the disease, the skin not only loses this acrid and burn- 
ino- heat, but frequently becomes cooler than natural. Sir Gilbert 
Blane, in his excellent description of tj-phus, studied mostly on 
ship-board, says, — "The symptom, next to be taken notice of, 
thouD-h a minute one, is verv constant and characteristic in this 
sort of fever. It is a peculiar heat in the skin, communicated to 
the hand of another person. It is usual to grasp the wrist of the 
patient after feeling his pulse, in order to examine the state of the 
skin in point of heat and moisture ; and in doing this a glow of 
heat is impressed on the palm of the hand, which lasts for some 
hours, if one should neglect so long to wash the hands. "^ In 
connection with the same subject, a still older, and equally care- 
ful observer. Sir John Pringle, remarks, — **In the beginning, the 
heat is moderate; even in the advanced state, on first touching 
the skin, it seems inconsiderable ; but upon feeling the pulse for 
some time, I have been sensible of an uncommon ardor, leaving 
an unpleasant sensation on my fingers for a few minutes after. 
The first time I observed this, I referred it to the force of imagi- 
nation; but I was assured of the reality by repeated experiments; 
and by the testimony of others, who, without knowing of my ob- 
servation, had made the same remark."^ 

Most writers upon this disease speak of the odor from the body 
of the patient. Southwood Smith calls it peculiar, and character- 
istic, but does not attempt to describe it. John Cheyne mentions 
the oflfensive fetor from the patient. Dr. Gerhard is more explicit 
upon this point. He says, that this peculiar odor was pungent, 
ammoniacal and offensive; especially in severe cases, and in fat, 
plethoric, individuals; sometimes, for a few days before death, 
the smell resembled that of putrid animal matter. The bodies of 
these patients ran into decomposition very rapidly after death, 

1 Dub. Hos. Rep., vol. ii. p. 10. 2 Obs. Dis. of Seamen, p. 355. 

3 Obs. Dis. of Army, p. 259. 



SYMPTOMS.— PULSE. 177 

although, before putrefaction, the odor was less pungent, than it 
was during life. Dr. Pickels says, that upon entering the room 
of a patient, the presence of typhus fever was indicated, previous 
to any examination, by this peculiar fetor from the skin. Dr. 
Doane informs me, that many of the emigrant patients, with ty- 
phus fever at the New York quarantine hospital, give out an odor, 
which he describes as sour, dirty, and offensive. 

Sec. III. — Pulse. The pulse is generally very frequent. In 
severe and fatal cases, it is often more than one hundred and 
twenty in the minute, and not unusually as high as one hundred 
and fifty. Of two hundred and thirty-seven cases, in the Hard- 
wicke Fever Hospital, the average frequency of the pulse, on the' 
day of admission, was from fifty-two to seventy-eight, inclusive, 
in twenty-seven ; from eighty to one hundred, inclusive, in seventy- 
nine ; from one hundred and two to one hundred and twenty, in- 
clusive, in ninety-five ; and from one hundred and twenty-four to 
one hundred and eighty, inclusive, in thirty-six.^ The rapidity of 
the circulation was, generally, but not uniformly, proportionate to 
the excess of temperature. Sometimes, though rarely, the fre- 
quency of the pulse, even in very grave cases, is below the natural 
standard. It is nearly always regular. Dr. Gerhard says, that 
the peculiar undulation in the motion of the artery, so frequent 
in typhoid fever, was rarely felt in the Philadelphia typhus of 
1836. 

Other characteristics of the pulse are not very easily and accu- 
rately defined. It is safe, however, to say, that the pulse very 
rarely, if ever, exhibits the strength, hardness, and sharpness, of 
inflammatory diseases. Sometimes, early in the fever, it may be 
somewhat full, but even then, it is easily compressed; and after 
the first few days, it is almost always small, soft, and feeble. 

In this connection, better than anywhere else, I may speak of 
the feeble action of the heart. This feebleness in the contraction 
of the central organ of the circulation is particularly mentioned 
by Dr. Stokes of Dublin, and other writers on typhus fever. Dr. 
Gerhard found it extreme in many cases, even from the earliest 
period of the disease.' 

* Dub. Hosp. Rep., vol. il p. 4. 

12 



178 TYPHUS FEVER. 

ARTICLE III. 

THORACIC SYMPTOMS. 

In most cases of typhus, there is some lesion of the respiratory 
organs, manifesting itself by signs or symptoms during life. Dr. 
Gerhard found, early in the disease, a feeble and imperfect re- 
spiratory murmur over the posterior portion of the chest, with 
corresponding dullness on percussion. These signs were frequently, 
but not always, combined with a subcrepitant, or mucous, rhon- 
'chus. This latter was more common during the cold, than during 
the warm, weather. The sibilant rhonchus, common in typhoid 
:fever, was rare in this epidemic. Pneumonia constituted the 
most frequent accidental complication, especially in the winter. 
It was indicated by a loose mucous rhonchus, instead of the fine, 
dry crepitus, and bronchial respiration, of simple pneumonia, and 
was unattended by pain. 

Dr. Pickels says, that in the typhus fever of 1817, 1818, and 
1819, in Cork, next to the affection of the head, the most promi- 
nent and constant feature was the affection of the chest ; as marked, 
during the first days, by oppression of the precordia, sighing, and, 
in the course of the disease, by cough. The cough was generally 
accompanied by a copious and viscid expectoration, and was 
especially urgent, early in the disease, during the winter months.-^ 

The frequency of respiration, during the active period of the 
disease, is increased. Of one hundred and seventy-one cases, 
admitted into the Hardwicke Fever Hospital, during the spring and 
summer of 1817, the average frequency of the respiration, on the 
day of admission, was about thirty in the minute. It ranged from 
twenty to thirty, inclusive, in eighty-four cases; from thirty-two 
to forty, inclusive, in seventy-seven cases; and from forty-four to 
sixty, inclusive, in ten cases. ^ 

Of two hundred patients, treated by Dr. Henderson at the 
Edinburgh Royal Infirmary, in 1838, and 1839, there were symp- 
toms of thoracic disease, in seventy-three. In a large majority 
of these cases, the symptoms were bronchitic.^ 

^ Trans, of Phys. of Ireland, vol. iii. p. 198. 

2 Dub. Hos. Rep., vol. ii. p. 11. 

3 Edin. Med. and Surg. Journal, Oct. 1839. 



SYMPTOMS.— HEADACHE. 179 

ARTICLE IV. 

CEREBRO-SPINAL, OR NERVOUS, SYMPTOMS. 

Amongst the most constant and prominent symptoms of typhus 
fever, are those connected with the nervous apparatus. They ob- 
trude themselves urgently upon our observation; they are striking, 
and strongly marked, in their character; they are many in number; 
they are present at the earliest poiod of the disease; and they ac- 
company its various stages up to the time of convalescence. Not- 
withstanding all this; for the very reason, perhaps, that it is so, 
I am unable to give anything like so full and discriminating a 
history of this extensive and important class of symptoms, as I 
have given of the corresponding symptoms, in typhoid fever. The 
British writers upon typhus fever do not seem to have considered 
it at all necessary to speak with any considerable degree of par- 
ticularity of these symptoms ; so that it is impossible, in the actual 
state of our knowledge, to make so satisfactory a comparison, in 
this respect, between typhus and other fevers, as is desirable. 

Sec. I. — Headache; Pains in the Back and Limbs. Pain in 
the head is almost always present, during the early period of 
typhus fever. Dr. Gerhard does not speak of it, in his general 
description; but it is mentioned in all his reported cases, eight in 
number. It is very commonly amongst the premonitory symp- 
toms of the disease ; and if not present at this time, is very sure 
to constitute one of the signs of its formal and more decided at- 
tack. Dr. Henderson found it in one hundred and fifty, of one 
hundred and fifty-nine cases; it was present on the first day, in 
ninety-two, of one hundred and eight cases ; and its mean dura- 
tion was ten days.^ Dr. Pickels says of the Cork epidemic, in 
1817, 1818, and 1819, — "the most distressing source of uneasi- 
ness was the headache, the patient, when questioned, complain- 
ing, in almost every instance, particularly of this pain; and often 
using some comparison, illustrative of its acuteness. It was com- 
monly referred to the forehead, more particularly over the eyes; 
rarely to the occiput. In a few instances it w^as dull and verti- 

* Edin. Med. and Surg. Journ., vol. lii. p. 432. 



180 TYPHUS FEVER, 

ginous. " Dr. Stewart informs us, that of one hundred and thirt}-- 
nine cases, occurring at Glasgow, the headache was present, after 
the fifth day, in ninetj-eight ; that in between one-sixth and one- 
seventh of this number it ceased before the tenth day ; but that in 
the remaining five-sixths it continued throughout the advanced 
stages of the disease, and in eleven throughout the whole course 
of the affection.^ The headache is usually accompanied by pains, 
more or less constant and severe, in the back, and in the extremi- 
ties, particularly the legs. 

Sec^ n. — State of the ^End. The mind is almost always more 
or less affected, from the commencement of the disease. This 
affection may consist, for the fi.rst few days, merely in a diminu- 
tion of its usual strength, and activity. The patient feels himself 
confused, and cloudy, and hesitating in his thoughts. His accus- 
tomed aptitude for intellectual effort is lost. Dr. Gerhard says, 
that in the Philadelphia epidemic of 1836, — ^' the alteration of 
the intelligence was so slight at first as to escape the attention of 
an inexperienced obserrer; but when the fever had fully set in, 
there was at least confusion of the intellect, and nearly always, 
delirium. This last symptom was -absent in only a few cases. The 
delirium was not noisy, except in about one patient out of twenty. 
In the immense majority of patients, it was dull, muttering, aud 
incoherent. The delirium became more tranquil, and was ex- 
changed for ordinary stupor, or coma, when the fever was at its 
height. It did not cease entirely, untU the complete establish- 
ment of convalescence. Even after recovery, the intellect of the 
patient was more enfeebled, than it is in ordinary diseases, and 
regained its usual strength but slowly." 

In the Irish epidemic at Cork, already spoken of. Dr. Pickels 
says, — " the patient commonly raved of those objects, which had 
principally engrossed his attention during health. A cow-herd, 
who had been brought in from the country, fancying that the 
patients who lay around him, were those animals which he had 
been accustomed to attend, endeavored at intervals to rouse them 
into motion by a particular cry, which is usual for this purpose, in 
the country. A thief raved of his thefts and accomplices. A 
faithful steward refused, with many acknowledgments, to take his 

' Edinburgh Med. and Surg. Joum.. Oct 1S40. 



SYMPTOMS.— STATE OF THE MIND. iSl 

wine, as he had his master's keys, and it might render him unfit 
to perform his business." Hildenbrand says, — " During the sep- 
tenary stage of an attack of typhus, my mind was constantly en- 
gaged in removing an awkward ornament from my stove, which 
stood directly opposite to me; and, being of course unable to re- 
move it, it tormented me in the most cruel manner. One of my 
pupils, who, having been taken with an attack of typhus a short 
time previously, had assisted at the opera, called the Mirror of 
Arcadia, performed, during the whole septenary of the nervous 
stage, the character of viper-catcher ; and as he was obliged to 
swallow these disgusting reptiles, he experienced the most inex- 
pressible anxiety. Another labored under the painful and fantas- 
tic idea, during the whole course of his disease, that he was not 
only suffering for himself, but for all his comrades in the clinical 
w^ard.''^ Dr. John Cheyne informs us, in his account of typhus 
fever at the Hardwicke Hospital, Dublin, in the summer of 1818, 
that in severe cases, delirium came on at the end of the first, or 
at the beginning of the second, week. " At all times, such pa- 
tients were incapable of any stretch of attention; they answ^ered 
questions satisfactorily, though with a faltering voice, but soon 
wandered from the subject. In many cases, the delirium was of 
a very troublesome kind ; first, it was only occasional ; then, it 
continued all night ; then, it was uninterrupted. We had many 
patients who created great disturbance by wandering about the 
w^ards all night, prying into the closets, and looking under the 
beds. Some of these were full of their usual occupations : one 
man, by trade a cooper, endeavored to pull his bed to pieces, in 
order to make a tub of the spars." It ought, perhaps, to be stated 
here, that many of the patients in the Irish hospitals, were habitual 
spirit drinkers; and it is very probable, that in some of these 
cases the elements of delirium tremens may have been combined, 
to some extent, with those of the fever itself. 

In twenty-three cases, amongst females, noticed by Dr. Hen- 
derson, at Edinburgh, the delirium began, on an average, about 
the eleventh day. Dr. Henderson found no appreciable relation 
between the disturbance of the mental powers, and the degree of 
pain in the head. The average date at which delirium showed 
itself, amongst male patients, was about the tenth day : it occurred, 

^ Gross's Hildenbrand, p. 45. 



182 TYPHUS FEVER. 

also, in a greater proportion of cases amongst males, and was 
oftener of a violent character. 

Another very constant symptom, belonging to this group, con- 
sists of somnolence, or stupor, in its various degrees. This is 
amongst the earliest phenomena of typhus fever. Dr. Gerhard 
says, — " it was perceptible in our patients, from the moment when 
they complained of their first symptoms. It was frequently slight, 
but could always be recognized by a little attention, and gradually 
increased until the middle period of the disease, when it was most 
intense; nor did it cease entirely until the strength of the patient 
had returned. There were usually some traces of it during con- 
valescence. The stupor rarely passed into complete coma, except 
in fatal cases; hence coma was always a mo^ unfavorable sign. 
Still, to a moderate extent, it was occasionally witnessed, without 
being followed by the same danger, as in ordinary diseases." Dr. 
Pickels observes, that in cases marked by stupor, even where 
there had been no delirium, the patients, upon recovery, seemed 
to have lost all recollection of what length of time they have been 
sick. 

The sleep is imperfect, unrefreshing, and disturbed; and it 
continues to be so, until it lapses gradually into coma, or until 
the patient falls into the deep and sweet repose of commencing 
convalescence. 

Sec. III. — Physiognomy. Besides the dull and stupid expres- 
sion of the countenance, common both to typhoid and to typhus 
fever, there are other appearances of the face, more characteristic 
of the latter disease. These consist in a peculiar state of the 
skin, and the eyes. They are very generally mentioned by 
writers on typhus fever, and are particularly described by Dr. 
Gerhard. "A constant symptom," — he says, — "observed in 
every case, was a dull, livid, red hue of the countenance, extend- 
ing nearly over its whole surface. Sometimes, this color ap- 
proached a purple. It coincided with a strong, dark red suffusion 
of the capillary vessels of the conjunctiva, which appeared at the 
same time with it ; but it usually disappeared at an earlier stage 
than the injection of the eyes. The conjunctiva never presented 
the bright red tinge, or the brilliant aspect, observed in acute 
inflammatory diseases of the brain, or of the eye itself. The ex- 
pression was dull, and the blood-vessels had a dark red tinge, 



SYMPTOMS.— SENSES.— MUSCLES. 183 

instead of their usual scarlet hue. The suirusion of the face and 
eyes was so constant, and so well marked, in the fully formed 
disease, that it served almost as a pathognomonic sign. It was 
generally most evident in patients of a full habit of body. To- 
wards the close of the disease, the reddish color was gradually 
changed into a dull ashen tint, which remained until the entire 
recovery of the patient." 

Sec. IV. — State of the Senses. Several of the senses are com- 
monly more or less perverted in the course of typhus fever. 
Some confusion of vision is frequently present, from the begin- 
ning of the disease. This is often associated with dizziness, 
especially on assuming the sitting or upright position. Dullness 
of hearing, commonly connected with ringing in the ears, is also 
an early, and a very common symptom. Dizziness was present 
in five of nine cases, observed at London by Dr. Shattuck, Jr., 
and dullness of hearing, in only one. Dr. Stewart mentions great 
intolerance of light, as one of the most constant symptoms of the 
disease. 

There is often a morbid sensibility of the entire surface of the 
body. Dr. Gerhard observed, in the Philadelphia epidemic of 
1836, that, "the sensibility of the skin was universally augmented 
when the stupor was not so great as to render the patient insen- 
sible, or nearly so, to all external impressions. The tenderness, 
upon pressure, was so much increased, as to induce us to refer 
the external soreness at the epigastrium, when pressure was made 
upon the abdomen, to an affection of the internal organs; but on 
more careful examination, the sensibility was nearly equally in- 
creased, in every part of the body, and was evidently external. 

" The cutaneous tenderness was preceded by muscular sore- 
ness, which lessened as the skin became more sensitive." 

Sec. V. — State of the Muscles. Amongst the earliest and most 
constant accompaniments of typhus fever, is loss of muscular 
strength. This is almost invariably present from the beginning 
to the close of the disease. Even during the premonitory stage, 
when this exists, it is with much difficulty and effort, that the 
patient succeeds in keeping from his bed. Dr. Pickels, in his 
Report on the Typhus Fever at Cork, says, "the debility was such,, 
that the patient was unable, from the commencement, to rise from. 



184 TYPHUS FEVER. 

the bed, or to walk without assistance, and in some instances, 
even without the effort of rising, fainted in bed. In a few, syn- 
cope appeared, as the first symptom of the onset of the disease. 
There is a secondary and still more extreme prostration of strength, 
which comes on, on the subsidence of the fever, and is attended 
with coldness of the extremities, and a feeble, fluttering, pulse. ^ 
Spasmodic twitchings of the muscles are very common in 
typhus, as they are in typhoid, fever. Their positive frequency, 
I am not able to give. Dr. Gerhard observed subsultus of the 
tendons at the wrist in three-fourths of his patients. ^' In the more 
severe cases," — he says, — "the subsultus extended to the mus- 
cles of the legs and face. When it appeared at the face, the 
corners of the mouth were drawn rapidly to one side or the other, 
giving a singular expression to the countenance. In the worst 
cases, the subsultus extended to nearly all the muscles of the 
body, keeping the patient in a constant state of tremor, not unlike 
a severe chill. The smaller muscles were much more affected 
than the jarger ones, and there was no constant rigidity observed 
in any case ; neither was there any paralysis." It will be seen, 
from what has now been said, that the symptoms connected with 
the nervous system are even more constant, and more strongly 
marked, in typhus than in typhoid fever; but that there is no 
very constant or important difference between them, unless it be 
in the greater degree of stupor attending the former, and in the 
earlier and more rapid development of these symptoms. 

ARTICLE V. 

DIGESTIVE AND ABDOMINAL SYMPTOMS. 

Sec. I. — Tongue, and Mouth. The appiearance of the tongue 
in this disease is very various. In mild cases, it frequently con- 
tinues moist, and is merely covered with a light- colored, thin, 
coating; this may become brownish, as the disease proceeds. In 
other, and in grave cases, the tongue is dr}^, cracked, glazed, 
trembling when protruded from the mouth, and of various shades 
of color, from the light brown, already mentioned, to black. It 
may be of a deep, glossy red, color. Sometimes, and in certain 

* Amer. Jour. Med. Science, Aus. 1837. 



SYMPTOMS.— APPETITE.— NAUSEA AND VOMITING. 185 

stages of the disease, it has a dark, yellowish or brown, dry stripe 
along its middle, while the edges are nearly clean and moist. Dr. 
Henderson studied the state of the tongue very carefully in a large 
number of cases at Edinburgh, in 1838 and 1839. "It very 
early became covered," — he says, — "with an increased and 
altered secretion; white, yellow, or ash-colored; viscid, and ad- 
hering to the surface ; becoming commonly thicker and darker, 
as the disease advanced. A dry state of the tongue began chiefly 
in the second week of the fever, and continued for the most part 
without change, until, along with other symptoms of convalescence, 
the tip and edges assumed a moist and clean appearance, which 
gradually extended to the rest. The dryness was often confined 
to the centre of the tongue, extending in a brown streak from the 
point backwards."^ Accompanying these morbid states of the 
tongue, there is very frequently an accumulation of dark sordes 
upon the teeth and gums, and fetor of the breath. Dr. John 
Cheyne, in his Hardwicke Hospital Report, for 1818, says, that 
there was often an inability to protrude the tongue, w-hich very 
awkwardly obeyed the will of the patient. "He would open his 
mouth, and after various unsteady motions, at length force out his 
tongue ; and when this was accomplished, it was not again draw^n 
within the mouth until he was repeatedly admonished to that 
effect." 

Sec. II. — Appetite. The appetite is generally destroyed, al- 
though it w^ould seem to be less constantly and entirely wanting 
in typhus, than in typhoid fever. Amongst the blacks at Phila- 
delphia, in 1836, the appetite sometimes continued, and some of 
them asked for and ate solid food. At the Cork Street Fever Hos- 
pital, during the summer of 1816, when the prevailing character 
of the fever was very mild. Dr. William Stoker noticed, as a re- 
markable peculiarity, the continuance of a considerable degree of 
appetite, even whilst the fever was urgent. In two fatal cases, a 
desire for food was expressed a few hours before dissolution. 

Sec. III. — JYausea, and Vomiting. Nausea and vomiting are 
occasionally present, at the commencement of the disease; but 
the proportion of cases, in w^hich they occur, and the difference 

* Edin. Med. and Surg. Journal, Oct. 1839. 



186 TYPHUS FEVER. 

in this respect, if any such exists, between typhus and typhoid 
fever, I have no means of ascertaining. In the Philadelphia 
epidemic of 1836, both nausea and vomiting were extremely rare. 
Dr. Gerhard says, that he scarcely found either of these symptoms 
noted in a single case. There may be a good deal of difference 
in their frequency, in different seasons, and localities. I have 
already stated, that Dr. Pickels says, the fever at Cork in 1817, 
1818, and 1819, was, in almost every instance preceded by 
nausea, or, as the patient expressed it, by an empty straining. 
Dr. Anderson says, that nausea was present in fourteen of eighteen 
cases observed by himself, on the first day of the disease. In 
nine cases, observed by Dr. Shattuck, at the London Fever Hos- 
pital, there was neither nausea, vomiting, nor epigastric pain. 
Amongst one hundred and thirty-two female patients, treated at 
the Royal Infirmary of Edinburgh, in 1838 and 1839, nausea and 
vomiting were ascertained to have been present in only twelve, 
chiefly at the beginning of the fever. 

Sec. IV. — State of the Bowels. In a majority of cases, there 
is very little, if any, obvious change, either in the shape or feel of 
the abdomen. When it is at all tympanitic, it is only slightly so. 
Dr. Gerhard says, that in many patients, it w^as either retracted, 
or altogether of the natural form. Dr. Stewart found moderate 
meteorism, in only seventy-four of four hundred and sixty-three 
cases. Tenderness on pressure, either over the whole abdomen, 
or over the epigastrium, is frequently spoken of by writers on 
typhus fever; but it is probable, that in' many cases, this has de- 
pended upon the morbid sensibility of the skin. Of Dr. Shattuck's 
nine cases, there was meteorism in only one ; and in this, but for 
a single day. Oftener than otherwise, the bowels in typhus fever 
are constipated. This is as true of grave as it is of mild cases ; 
and it is, also, as true of the late as it is of the early periods of 
the disease. Spontaneous diarrhoea is as rare a symptom in typhus 
as it is a common one in typhoid fever. It is hardly seen, indeed, 
in the former disease, excepting during certain seasons, especially 
in the summer and autumn, when there exists a general predis- 
position to intestinal irritation and inflammation. Under such 
circumstances, typhus fever feels, as any other disease might, the 
influence of the prevailing pathological tendency. Dr. Stewart 
found diarrhoea in only twenty-three of one hundred and thirty- 



SYMPTOMS.— ABDOMINAL. 187 

nine cases. Dr. Henderson, in one hundred and fifty-four cases 
of typhus, found the bowels easy in ninety-nine, loose in five, and 
costive in fifty. Dr. West, in his paper on Exanthematic Typhus, 
says, — *' The action of the bowels was not disturbed, in the great 
majority of cases; in fact, the administration of mild laxatives 
was necessary, in most instances, in order to obtain an evacuation 
once in forty-eight hours ; and in some of the most severe cases, 
the bowels were very constipated. Diarrhcea occurred in only ten 
of sixty cases; in three of which, the patients died, and it was 
only four times that it lasted longer than forty-eight or sixty hours." 
"The intestinal evacuations," — says Dr. Henderson, — "in their 
most disordered state, were very dark, slimy, and offensive ; and 
in a more or less considerable degree they possessed these charac- 
ters in almost every case ; a few only of the mild, and one or 
two of the protracted, cases, having had throughout stools of a 
light yellow color." Dr. Edward Percival speaks of the stools, 
in a certain number of cases, as being " unctuous or pitchy, of a 
black, or greenish, hue; and either preternaturally fetid, or un- 
usually inodorous." It is hardly necessary to call particular at- 
tention to the very constant and striking difference, which exists 
in the condition of the bowels, in typhus, and in typhoid, fever. 
Epigastric distress and tenderness are spoken of by Dr. Cheyne, 
and by many others, as frequently present, especially during the 
summer and autumn, when there are other symptoms of disturb- 
ance of the stomach. Of one hundred and thirty-nine cases, 
reported by Dr. Stewart, there w^as abdominal pain, somew^hat 
permanent, in ninety-six; and in sixty of these, it continued 
throughout the greater part of the illness. In most cases, the 
pain was general ; in thirty-two, it was chiefly or entirely confined 
to the region of the liver; and in half of these, it was associated 
with great tenderness on pressure. In eleven instances only, was 
there any pain in the right iliac region. Dr. Stewart observes, 
that while in typhoid fever, the pain accompanies the diarrhoea ; 
in typhus, the pain is oflen most severe w^hen the bowels are cos- 
tive, and is relieved by the exhibition of a purgative.^ Dr. Stew- 
art found, indeed, that of seventy-seven cases of typhus, in which 
diarrhoea, either spontaneous or consecutive, was noticed, there 
was accompanying abdominal pain in only thirty; while of sixty- 

* Edin. Med. and Surg. Journ., Oct. 1840. 



188 TYPHUS FEVER. 

two cases, in which the bowels were confined, abdominal pain 
and constipation co-existed in no less than twenty-one. A similar 
relation between these two symptoms was noticed by Dr. West. 
It can hardly be necessary for me to call attention to the very 
wide and striking difference between the abdominal symptoms in 
typhus and typhoid fever. 

Hemorrhage from the bowels is of extremely rare occurrence. 
Dr. Henderson saw only one instance of this, amongst two hun- 
dred patients, at the Royal Infirmary of Edinburgh, in 1838, and 
1839. 

ARTICLE YI. 

MISCELLANEOUS SYMPTOMS. 

Sec. I. — Emaciation. There is not much obvious wasting of 
the body, in the early periods of typhus fever. Dr. Gerhard did 
not find it to become very evident, until the fever began to decline. 

Sec. II. — State of the Urine. I am not aware that the changes 
in the quantity and character of the urine in typhus fever have 
been, to any great extent, accurately studied. Dr. Gerhard says, 
that in the Philadelphia epidemic, the urine ''was examined very 
attentively, and was remarkable merely for its extraordinary free- 
dom from brick-red deposit, or the changes so frequently observed 
during the course of fever." Dr. Edward Percival says, that the 
quality of the urine is too variable to place any dependence upon 
it. This, however, is in reference to prognosis. Dr. William 
Stoker says, that in the early stages of the disease, the urine is 
scanty, and high-colored. Retention of the urine is not uncom- 
mon in bad cases, constituting a distressing, and, if overlooked, 
as it is very likely to be, a dangerous complication. 

Sec. m. — Epistaxis. Hemorrhage from the nostrils, so common 
in t\'phoid, seems to be not a very frequent occurrence in typhus 
fever. Dr. Gerhard does not mention it at all. By some writers, 
however, it is spoken of, as a more common and important symp- 
tom. Dr. Pickels, in his report on the Cork epidemic, says, — 
"bleeding from the nose, though often occurring separately, in a 
majority of instances appeared in petechial cases. The discharge 



SYMPTOMS.—CUTANEOUS ERUPTIONS. 189 

did not usually exceed a few drops, but continued to recur during 
some days. In two cases, however, which proved fatal, the dis- 
charge was so profuse, as to fill vessels of considerable size. 
Bleeding from the nose came on, in a majority, on the second 
day, rarely appearing later than the seventh ; it was much more 
common amongst males, than females." Dr. F. Barker speaks 
of its occurrence occasionally, and adds that no other hemorrhage 
is common. 

Sec. IV. — Cutaneous Eruptions. Typhus fever is very generally 
attended with a peculiar and characteristic eruption upon the 
skin. The name of the disease has often been derived from this 
circumstance ; hence it has been called petechial fever, spotted 
fever, maculated fever, and so on. As to the exact frequency of 
the occurrence of this eruption, it is impossible to speak with 
entire certainty. In many cases, it has probably been overlooked ; 
and besides this, it is to be remembered that the diagnosis of 
typhus fever, by many who have written most extensively, and 
most magisterially, upon the subject, has been anything but rigor- 
ous and careful. Dr. Stewart remarks, — "that the eruption of 
typhus was unnoticed at Edinburgh, until the attention of phy- 
sicians was called to it by Dr. Peebles, in 1832;" he says further 
— "It is also well known, to many, that, previous to a visit which 
Dr. Peebles made to the Glasgow Fever Hospital, in the spring 
of 1835, the exanthema of typhus, then found to be of general 
occurrence, had neither been looked for, nor registered, in that 
institution, and was received as a new discovery." These con- 
siderations may help to account for the differences, which are to 
be found, in different histories of the disease, in relation to this 
particular subject. In the Philadelphia epidemic. Dr. Gerhard 
says, — "it was present in thirty-two of thirty-six whites. Of the 
four cases, in which it was not visible, one died upon the seventh 
day of the disease, and the others presented slight symptoms of 
fever, which disappeared in the course of four or five days. It 
was also visible, though less distinctly, in mulattoes; and we may 
infer that the color of the skin alone prevented its development in 
the nesrroes." 

This eruption differs, in many respects, and in a very striking 
degree, from that of typhoid fever. Its color, especially after the 
second or third day of its appearance, is that of a duller and 



190 TYPHUS FEVER. 

darker red. The spots are of a dun, dusky, purplish hue; in 
some cases, they become almost black. They vary in size, from 
that of a minute point, to a diameter of a line, or even of an 
eighth of an inch. They are less regularly circular or oval, than 
the rose spots of t3rphoid ferer. They are not elevated above the 
surrounding skin, and disappear but very partially, or not at all, 
on pressure. They are, almost always, much more numerous, 
than the spots of t^*phoid fever; covering, in many cases, the en- 
tire trunk, and the extremities. Sometimes, they are spread over 
the skin, almost as thickly as the eruption of measles. Dr. Pickels 
says, that in the Cork epidemic, ''the spots were principally ob- 
served upon the breast, neck, shoulders, arms and thighs ; rarely 
upon the face. From their resemblance, in some instances, to 
freckles, the friends of the patients, in their descriptions at the 
dispensary, sometimes compared the appearance of the skin 
covered with them, to that of a turkey egg. The mottled or 
marbled efflorescence, resembling measles, occurred in several."^ 
Huxham says, — "We frequently meet with an efflorescence, also, 
like the measles, in malignant fevers, but of a more dull and lurid 
hue, in which the skin, especially on the breast, appears, as it 
were, marbled, or variegated." Pringle's description of the 
eruption is in these words: "There are certain spots, which are 
the frequent, but' not inseparable, attendants of the fever in its 
worst state. These are less usual on the first breaking out in the 
hospitals; but when the air becomes more corrupted, the spots 
are common. They are of the petechial kind, of an obscure red 
color, paler than the measles, not raised above the skin, of no 
regular shape, but confluent. The nearer these spots approach 
to a purple color, the more ominous they are, though not abso-. 
lutely mortal." The eruption sometimes fades suddenly, or 
changes in its color. Dr. Stewart, amongst others, has, within a 
few years, studied with great care and particularity, the character 
and appearances of this eruption. He says, that the rash is per- 
manent; that is, that it does not consist of successive eruptions of 
spots; that, in all cases, it presents the two periods, longer or 
shorter, of increase, and decline; and, that, in the more severe 
cases, it may exhibit, during the period of increase, four different 
states, being florid, dark, livid, and petechial. When the hue of 

' Trans, of Phys, of Irelandj vol. iii. p. 199. 



SYMPTOMS.—CUTANEOUS ERUPTIONS. 191 

the eruption is florid, it disappears readily under pressure ; Avlien 
dark, it still disappears, but more slowly; when livid, semi-pete- 
chial,or pseudo-petechial, as it has been called, it is only partially 
eflaced ; and when petechial, it is not in the least aflectcd by 
pressure. In many cases, it remains florid throughout; in others, 
it presents one or more, and in not a few, all these alterations ; 
and after it has reached its height, the process is inverted, and it 
passes through the various phases of lividity, darkness, redness, 
and paleness, before its evanescence." Of one hundred and 
thirty-nine cases of typhus, observed by Dr. Stewart, the erup- 
tion was pale, in about one-fourth ; florid, in between one-sixth 
and one-seventh; darkish, in between one-eighth and one-ninth; 
livid, in rather less than one-ninth; and petechial, in about one- 
eighth. 

Dr. Stewart ascertained the exact time of the appearance of the 
eruption, in fifty-two cases. This time varied from the second, 
to the thirteenth, day; but in twenty-nine cases, more than half 
of the entire number, it appeared on the fifth or sixth day ; and 
in three-fourths, it appeared from the fourth to the seventh day. 
In forty-eight cases, the eruption began to decline at different pe- 
riods, from the eighth, to the nineteenth, day. It was still more 
irregular in the time of its disappearance, since this ranged from 
the thirteenth, to the thirty-first, day. The average duration of 
the eruption was eleven and a half days.^ 

Dr. Henderson, of Edinburgh, has also observed, with an atten- 
tion, and thoroughness, not inferior to those of Dr. Stewart, the 
appearances of the cutaneous eruption, and very generally with 
similar results. Dr. Henderson noticed that, as a general rule, 
the progress and development of the eruption corresponded with 
the increasing severity of the other symptoms of the disease ; and 
that, in like manner, the decline of the eruption was nearly simul- 
taneous with the first signs of convalescence. He found, also, 
that the mortality and duration of the disease were very noticea- 
bly proportionate to the abundance of the eruption. Convales- 
cence was more protracted, in those cases where it was abundant, 
than in those where it was scanty.^ 

In Dr. Gerhard's cases, the eruption appeared from the sixth 
to the eighth day, after the commencement of the disease, and 

' Edinburgh Med. and Surg. Journal, Oct. 1840. 2 Ibid., Oct. 1S39. 



192 TYPHUS FEVER. 

gradually faded away and disappeared, from the fourteenth to the 
twentieth. 

Other eruptions, but none of them at all constant or character- 
istic, are occasionally observed in this disease. Amongst them, 
is that of sudamina, w^hich is sometimes seen, but not so frequently 
as in typhoid fever. A miliary eruption now and then shows 
itself over the whole body, remains for a few days, and then dis- 
appears ; the elevated cuticle failing off in a fine, branny, desqua- 
mation. Vibices are occasionally, though rarely, seen, near the 
fatal close of the disease. Dr. Stewart met with them in only 
two of one hundred and thirty-nine cases ; and with purpura spots 
in only three. Dr. Henderson saw only one vibex amongst two 
hundred patients, and sudamina in only three. 

In grave cases, there is sometimes noticed a dark livid or purple 
color of the skin of the extremities ; oftenest in the early, but some- 
times continuing through the entire period of the disease. 

General yellowness of the surface is not unusual, in certain 
seasons, especially during the latter part of summer and in the 
autumn, when it is common to find other signs of gastro-hepatic 
derangement. 

Sec. V. — Eschars. Gangrenous sloughs and ulcerations seem 
to be common in some epidemics of typhus fever, and rare in 
others. At Philadelphia, in 1836, they were present in only three 
or four cases in a hundred. Dr. Pickels says, that gangrene of 
the hips, nates, and shoulders was frequent, during the epidemic 
at Cork, in 1817, 1818, and 1819. Dr. O'Brien, in his Cork 
Street Hospital Report for 1820, informs us, that ulcerations and 
gangrene of the hips, nates, and sacrum were of very common 
occurrence; few of the malignant and protracted types of fever 
being exempt from them. Dr. Percival, of Dublin, says, — " gan- 
grenous extremities were extremely rare amongst my patients." 

Sec. VI. — State of the blood. Amongst these miscellaneous 
symptoms, may be mentioned the condition of the blood, when 
drawn from the body. In the epidemic at Philadelphia, the blood 
was examined in various stages of the disease, except where the 
state of the patient was such as to render the operation of blood- 
letting clearly improper. " At a very early period, it was dark, 
without the buffy coat, and offered a large, but soft, and dark 



SYMPTOMS— STATE OF THE BLOOD. 193 

colored, coagulum. At a more advanced stage, it presented in 
some patients the dissolved appearance, described by various 
authors as characteristic of the typhus or putrid fevers." Dr. 
O'Brien says, — " in those instances where blood was taken, in the 
advanced period of the disease, I have always found its texture 
broken down, and dissolved, changing rapidly into a greenish, 
watery fluid, with little coagulum ; indicating great dissolution of 
the animal fluids, and consequent great debility."^ Huxham has 
described quite fully, in his usual rich and excellent manner, the 
altered state of the blood in typhus.^ 



* Trans, of Phys. of Ireland, vol. i. p. 424. 
2 Huxham on Fevers, p. 41, «f seq. 



13 



194 



CHAPTER III. 

A^'ATO^IICAL LESIONS. 

The pathological alteratioiis, in :a:i- cases of tjphns ferer. 
have not been so thoroughly and accurately studied, as in the se 
of typhoid fever. Our knowledge of the anatomical lesions, ar, i 
of the condition of all the organs, after death, in the former dis- 
ease, is, of course, much less complete, than in the latter. Al- 
though the morbid anatomy of typhus fever has by no mean s l e t : i 
neglected by British observers, who have the best and mcs: rx- 
tensive opportunities for its investigation, it is nevertheless trae, 
that it has not been subjected by them to such comprehensi e. 
numerous, and detailed examinations, as the lesions in ty :. ::. 
fever have undergone, at the hands of Lcuis. A:::::?.', Chciie., 
BouiUaud, and others. Amongst the : : . :s • t : . - ^ 

materials for this portion of myhis: :y ,: :y-:.us ir ri. air ^e 
results of the investigations of Drs. Gerhard, and Pennock, during 
the Philadelphia epidemic of 1836. The number of autopsies, 
made bj these gentlemen, during the prevalence of the disease, 
was about fifty; and the fruits of their researches are especially 
valuable, on account of the entire confidence, which we may ftrl 
in their competency, as pathological observers; a confidence, 
which we are forced to withhold firom very ma:.y reyorters of the 
morbid appearances, in this as wel' cs i r. it: : s-^tS, Tir 
paper of Dr. Gerhard does not contcir. ? .y : : ^ : i^cl 

description of the state of the several ;r: -s, ar i lis :irScription 
I shall be obliged to make up firom th t s i :: : s t s : ^ h e 

anatomical lesions in which he has rail, uriy a-a.iiri. Laiar 
the years 1838, and 1S39, Dr. J an Reid, of Edinba _a :_ ?ir 
carefiil and thorou^ examia: :i:as z: ae bodies of be: ^a ::: :y 
and fifty patients, who died vi i: y iius fever, at the Plyai la- 
firmary of that city. These ex; aaa a as are reported, aai^ ana- 
lyzed, and compared with the syra as 
losophical, and with a comple:ea-ss as r 



_ ^ , ^ ., i t V 



LESIONS.— THORACIC ORGANS.— LUNGS. 195 

worthy the highest praise. They constitute a very valuable ad- 
dition to our knowledge of the lesions in this disease.^ With the 
materials derived from these sources, and with such others as are 
accessible and trustworthy, I shall endeavor to make out as full 
an account of the pathological anatomy of typhus fever, as in the 
present state of science it is possible to do. 

ARTICLE I. 

LESIONS OF THE THORACIC ORGANS. 

Sec. 1. — Lungs. The morbid alterations, which are found 
within the cavity of the chest, seem to be more constant and 
more important in typhus, than in typhoid fever. The lungs 
were more or less changed from their healthy condition, in all 
the cases reported by Dr. Gerhard. This change generally con- 
sisted in a somewhat peculiar condensation of a portion of one 
or both lungs. The tissue of the lung was more solid and heavy, 
than in its natural state; quite or nearly impermeable to the air; 
sometimes friable and sometimes not so; of a dark and sometimes 
a livid red; not granular, like hepatization, but resembling, in 
some degree, when torn, the structure of the spleen. This altera- 
tion was most frequent, in the lower and posterior portions of the 
organs. The mucous lining of the trachea and bronchial tubes 
was, in many cases, of a rosy red color, sometimes with a livid 
tinge ; but it was rarely changed, either in thickness or consist- 
ence. 

In two of the four cases, examined by Dr. Shattuck, Jr., at the 
London Fever Hospital, the lower lobes of the right lung were of 
a violet color, friable, not granulated, a great quantity of reddish 
liquid flowing out on cutting into them. In all the cases, the 
bronchial mucous membrane was injected, and lined by a con- 
siderable quantity of mucus. ^ 

Of forty-three cases, examined by Dr. Reid, in 1838 and 1839, 
there was more or less lesion of the lungs in all. In fifteen of 
these, the lesion consisted of simple congestion, at the most de- 

1 Between 1839, and 1841, Dr. Reid made careful dissections in one hundred 
additional cases of continued fever. The results of these examinations will be 
found in the present edition. 

2 Med. Exam., vol. iii. p. 150. 



196 TYPHUS FEVER. 

pendiD^ portion of the organs ; in thirteen cases, the posterior 
and middle parts of both lungs were gorged with blood, and 
frothy serum, and some portions were so dense, as not to crepitate 
when cut, though they did not present any granular appearance ; 
and in ten cases, there was increased effusion into the bronchial 
tubes.^ In thirty-nine of these cases, the brain was also exam- 
ined ; and it appears from a careful comparison, that extensive 
eno-oro-ement and congestion of the lungs were more frequently 
found associated with those cases, in which there was increased 
serous effusion within the cranium, than with those where this 
condition did not exist; indicating some special relationship be- 
tween the two phenomena.^ 

Sec. n. — Heart, and Blood. The heart was found, in some of 
Dr. Gerhard's cases, softened, flabby, and easily broken down ; 
in others, it was in its usual condition. 

The appearance of the blood, contained in the heart and in the 
large vessels, was striking and peculiar. It was of a very dark 
color, often almost black, thick in its consistence and sometimes 
oleaginous. In one case, the blood in the ca"V"ities of the heart, 
in the aorta, the vena cava ascendens, and in the femoral vein, is 
described as being like molasses, in color and consistence, with 
minute fatty globules floating in it. 

The substance of the heart, in Dr. Shattuck's cases, was not 
altered. In the right ventricle, there were from one to three 
ounces of black, liquid, blood ; and in three cases, a somewhat 
smaller quantity in the left. 

In all Dr. Reid's cases, the blood appeared to be in a fluid 
state, or nearly so, in the large veins ; but in several, a greater or 
less number of coagula, generally small and soft, were found in 
the right side of the heart. In two subjects, the blood, in the same 
situation, was in a grumous state. 

- Between 1S39 and 1S41, Dr. Reid examined the lungs in eightv-eight fevei 
cases, vrith. miicli the same general results. — Edin. 3Ied. Journ,, Aug. 1S42. 
2 Edin. Med. and Surg. Joum., Oct 1S39. 



LESIONS.— BRAIN. 197 

ARTICLE II. 

LESIONS OF THE BRAIN. 

In all the cases reported by Dr. Gerhard, there was unusual 
engorgement of the sinuses, and the larger vessels, of the brain. 
These were filled with dark colored, fluid, blood ; in some cases, 
in the large sinuses, surrounding a soft, greenish, coagulum. In- 
flammatory injection of the pia mater is not mentioned. Varying 
quantities of serum, from one or two drachms to one or two 
ounces, were found, in a certain proportion of cases, under the 
arachnoid, or within the ventricles. The medullary portion of the 
brain was frequently of a violet tinge ; otherwise, the substance of 
the organ was unaltered. In Dr. Shattuck's cases, observed at 
the London Fever Hospital, the organs in the cranial cavity pre- 
sented no remarkable lesions. In three of them, there was slight, 
sub- arachnoid, infiltration. Of forty-three cases, in which the 
brain was examined by Dr. Reid, in 1838 and 1839, there was 
increased effusion of serum, in twenty-five. This effiision, in a 
majority of instances, was situated between the arachnoid, and 
the pia-mater, and was commonly moderate in quantity, in many 
cases elevating the arachnoid above the surface of the convolu- 
tions only at the depending portions of the brain. Nearly all 
these patients exhibited more or less prominent cerebral symp- 
toms ; such as delirium, coma, subsultus tendinum, &c. ; but 
these symptoms were as frequently present, and as strongly 
marked, in the class of cases where there was no increased effu- 
sion of serum, as in the others. Of course, it is impossible to 
attribute the cerebral symptoms to the serous effusion. In every 
case but one, the blood-vessels of the brain are said to have been 
"well filled," and their congested condition was indicated by the 
number of bloody spots which appeared upon the cut surfaces of 
the organ, although these may have depended in part upon the 
fluidity of the blood. ^ Dr. Reid examined the brain in eighty- 
two additional cases of continued fever, between the years 1839 
and 1841, and the general results corresponded very nearly with 
those just stated.^ 

* Edin. Med. and Surg. Journ., Oct. 1839, 
2 Edin. Med, and Surg, Journ^ Aug. 1842, 



198 TYPHUS FEVER. 

Dr. John Cheyne reports a considerable number of dissections, 
during the epidemic of 1816, and 1817, in Dublin; but in 
many cases, the diagnosis of the disease is uncertain ; and in 
nearly all, the pathological appearances are so briefly and vaguely 
described, as to render them nearly valueless. During the sum- 
mer of 1816, he speaks of finding very frequently, what he calls 
appearances of inflammation, in the mucous membrane, both of 
the large and small intestines. In the following year, the abdo- 
minal viscera are represented as being generally sound, but he 
says : " Our expectations were never disappointed as to the state 
of the brain, unless that the diseased appearances in that organ 
were not always proportionate to the severity of the symptoms ; 
which denoted cerebral disturbance. The vessels of the head 
were turgid ; there was increased vascularity of the brain, espe- 
cially on its surface."^ 



ARTICLE III. 

LESIONS OF THE ABDOMINAL ORGANS. 

Sec. I. — stomach. The mucous membrane of the stomach 
was more or less altered, in all the cases reported by Dr. Gerhard. 
The most constant change consisted in softening of the membrane 
in the cardiac extremity, or grand cul-de-sac. This softening 
was sometimes confined to a small portion of the membrane ; 
sometimes, it was quite extensive. It varied in degree, from a 
moderate diminution of the consistence of the membrane, to its 
pulpy disorganization. In some instances, the softening extended 
to the other coats of the stomach. Mamellonation of the mucous 
membrane, especially towards the pyloric extremity, was not 
uncommon. In some cases, there was blue engorgement of the 
large veins ; in some, a pointed redness, and in others, a continu- 
ous, dull, slate color of the mucous coat. 

Sec. II. — Intestines. The intestinal canal, in all its tissues, and 
throughout its entire extent, was very constantly and remarkably 
free from disease in all Dr. Gerhard's cases. In the reported 
cases, no appreciable lesion is mentioned, excepting occasional 

> Dub. Hos. Rep^ vol. ii. p. 30. 



LESIONS.— ABDOMINAL ORGANS. 199 

spots, or patches, of ecchymosis. The examinations were tho- 
roughly made, and especial solicitude was felt, and corresponding 
carefulness was taken, to ascertain accurately the state of the 
small intestine, and its elliptical plates. Amongst the entire num- 
ber of autopsieSy there was but a single case, and that of doubtful 
diagnosis, in which there was the slightest deviation from the natu- 
ral appearance of the glands of Peyer. *^In the case alluded to, 
in which there had been some diarrhoea, the agglomerated glands 
of the small intestine were reddened, and a little thickened ; but 
there was no ulceration, and no thickening, or deposit of yellow 
puriform matter, in the sub-mucous tissue. The disease of the 
glands resembled that, sometimes met with in small-pox, scarlet 
fever, or measles, rather than the specific lesion of dothinenteritis. 

In all other cases, the glands of Peyer were remarkably healthy 
in this disease, as was the surrounding mucous membrane, which 
was much more free from vascular injection, than it is in cases of 
various diseases not originally affecting the small intestine." 

" The mesenteric glands were always found of the normal size, 
varying, as in health, from the size of a small grain of maize, to 
three or four times these dimensions. With the exception of a 
slightly livid tint, common to them and the rest of the tissues, 
they offered nothing peculiar either in consistence, or color. 

The spleen was of the normal aspect, in one half the cases ; 
in the other half, it was softened, but not enlarged, and in one 
case out of five or six, enlarged and softened. 

Thus, the triple lesion of the glands of Peyer, mesenteric glands, 
and spleen, constituting the anatomical characteristic of the do- 
thinenteritis, or typhoid fever, although sought for with the greatest 
care, evidently did not exist in the epidemic typhus. Indeed, it 
was a subject of remark, that in the typhus fever, the intestines 
were more free from lesion, than in any other disease accompanied 
by a febrile movement. This exemption extended to the large 
intestine, until the summer heats began, when a few scattering 
cases offered some symptoms of diarrhoea, during the prevalence 
of an epidemic dysentery; and, where they terminated fatally, 
softening and other signs of inflammation of the mucous coat of 
the colon were observed."^ 

The liver was found sometimes moderately softened; some- 

' Am. Journ. of Med. Sci., Feb. 1837. 



200 TYPHUS FEVER. 

times engorged with dark, fluid, oily blood, and sometimes spotted 
with ecchymosis. In many cases, however, it was the seat of no 
appreciable lesion. The contents of the gall-bladder differed in 
different cases : in some, the bile was viscid ; in some, it was 
thick, dark, grumous, and so on ; in others, it was healthy. The 
kidneys, in some instances, were of a darker color than natural, 
but commonly they were free from disease. 

In Dr. Shattuck's cases, the small intestine was generally 
healthy. The thickness and consistence of the mucous membrane 
were natural, and there was no lesion whatever of Peyer's patches, 
or of the mesenteric glands. In three of four cases, there was 
either redness, or softening, of the mucous membrane of the upper 
portion of the large intestine. In all the cases, the fecal matter, 
contained in the large intestine, was small in quantity, pultaceous, 
soft and yellowish. In two cases, the mucous membrane of the 
stomach was unaltered ; in two others, it was reddened, softened, 
or mamellonated. There was no constant lesion in the other ab- 
dominal organs.^ Of twenty-one cases, examined by Dr. Stewart, 
at the Glasgow Infirmary, the aggregated follicles w^ere distinctly 
elevated in two ; very slightly so in eight, not elevated in five, 
and scarcely visible in six. In none of them, was there any 
ulceration. Of thirty-three cases examined by Dr. Reid, in 1838 
and 1839, in the Edinburgh Infirmary, only two presented the 
follicular lesion of typhoid fever, and even these doubtfully. These 
had been protracted cases, and came from the country. Of the 
remaining thirty-one cases, Peyer's glands were distinctly elevated 
in four ; visible, but not elevated, in nine ; scarcely visible in seven ; 
and not visible in eleven. In none were they ulcerated.^ Between 
the years 1839 and 1841, Dr. Reid examined the intestines in 
ninety-one cases of continued fever. The result is very remarkable, 
and corresponds in a very striking manner with that of his previous 
investigations. The elliptical patches and solitary glands, were 
found in the following conditions, to wit ; — not visible to the naked 
eye, in six cases; scarcely visible, in seventeen; distinct but not 
defined, in four; defined, in eight; neither reddened nor elevated, 
in forty-four ; elevated, but not ulcerated, in six; elevated and 
ulcerated, in six. In all these last cases, the mesenteric glands 
were enlarged, and more or less softened. In two of them, there 

* 3Ied. Exam., vol. iii. p. 150. « Ed. 3Jed. and Surg. Journ., Oct. 1S39. 



LESIONS.— ABDOMINAL ORGANS. 201 

was perforation of the ileum, producing rapid and fatal peritonitis. 
Five of these cases occurred in laborers on the Glasgow railroad; 
and they had been for a short time previous to their illness located 
in Linlithgow or its neighborhood, about seventeen miles west 
from Edinburgh. Their average age was twenty-five years; the 
youngest was eighteen, and the oldest thirty- five. Dr. Reid says, 
— '^ During the whole three years and a half, that I conducted the 
post-mortem examinations in the Edinburgh Infirmary, in no 
single case did I observe, in any individual who had been seized 
with fever while residing in Edinburgh, anything resembling the 
changes described as occurring in the lower part of the ileum in 
the typhoid fever of Paris. "^ 

"Whether or not," adds Dr. Reid, "the typhoid and typhus 
fever be identical or difllerent diseases, we shall not venture at 
present to give an opinion; but if it should turn out that they are 
specifically the same disease, it would prove an interesting subject 
of inquiry to endeavor to ascertain, why the typhoid fever should, 
for several years past, never be found in Edinburgh, while it ex- 
isted at Linlithgow, Anstruther, and other places in Fifeshire." 
An interesting subject indeed! And is the inquiry any less in- 
teresting, why, if the diseases are specifically the same, one of 
them, with no constant lesion of the solids^ should be the common 
disease of Scotland and Ireland ; and the other, with a profound 
and peculiar anatomical lesion, should be almost the sole con- 
tinued fever of France and of the United States of America ! 
Is there any other disease that exhibits such a character? The 
Register of Dissections at the same institution, kept by Dr. John 
Home, from 1833 to 1837, showed, that of one hundred and one 
cases, only seven presented ulcerations of the elliptical plates. 
In two, there was perforation. These were probably instances of 
typhoid fever. Thickening, mamellonation, and other lesions of 
the mucous membrane of the stomach, were found in about one- 
fonrth of the cases. The spleen was generally larger than usual, 
soft, and in some cases, almost diffluent. In one instance, this 
organ weighed eleven, and in another, fourteen, ounces. 

Sec. III. — Miscellaneous. The petechial eruption frequently 
continues visible after death. In three of four cases examined by 

' Edin. Med. Jour., Au". 1S42. 



202 TYPHUS FEVER. 

Dr. Shattuck, the spots penetrated the thickness of the skin to the 
subcutaneous cellular tissue, and communicated to the parts they 
occupied a purplish color. 

Amongst the pathological phenomena of typhus fever, may be 
mentioned the tendency which manifests itself, in a certain pro- 
portion of cases, to early and rapid decomposition. Dr. Pickels, 
in his Report on the Typhus Fever at Cork, says, that this tend- 
ency was shown by the rapid putrefaction of bodies after death, 
rendering necessary their almost immediate interment. In many 
instances, the skin of the arms, thighs, and of almost the entire 
body, changed to a deep livid, or black, color, somewhat of the 
appearance as if scorched by gunpowder, several hours before 
death. ^ Dr. Gerhard noticed, that rapid putrefaction took place, 
especially in the bodies of those patients from whom the offensive, 
ammoniacal odor, already spoken of, had been most strongly per- 
ceived during life. 

Sec. rV". — General Remarks. The most striking fact in the 
pathological anatomy of typhus fever consists in the absence of 
any constant and characteristic lesion. One of the most uniform, 
and probably one of the most important alterations, is that of the 
blood. It seems to me, in the present state of our knowledge, 
quite idle and useless, to attempt to trace any obvious connection 
between the symptoms and the lesions, or, in other words, to refer 
the former to the latter. The broad and fundamental difference 
in the state of Peyer's glands, and the mesenteric glands, in ty- 
phus, and t}'phoid fever, will, of course, be noticed. 

1 Trans, of Vhys. of Ireland, vol. iii. p. 202. 



203 



CHAPTER IV. 

CAUSES. 

I SHALL enumerate, under this head, some of the principal cir- 
cumstances, which appear to favor the occurrence, and spread, 
of typhus fever. Our knowledge of its efficient causes, excepting 
that of contagion, is very limited and imperfect. 

Sec. I. — Locality. It is very evident, that the geographical 
boundaries, within which typhus fever prevails, as a common and 
more or less constant disease, are much less extensive, than those 
of typhoid fever. The actual extent to which typhus fever has 
heretofore prevailed, in different regions and countries, owing to 
the imperfect histories which have been left to us of this and of 
analogous diseases, and the consequent doubtfulness and uncer- 
tainty of our diagnosis, is a matter which it is now impossible to 
determine, with any considerable degree of precision. One thing 
is very certain, and that is, that typhus fever has always been of 
very rare occurrence in New England. Nathan Smith, one of 
the great observers of New England diseases, says expressly, that 
he never met with any other form of continued fever, than that 
which he has so well described under the then common name of 
typhus fevevy and which was, evidently, the typhoid fever of 
this work. Very few of the New England physicians, now 
living, I presume, have had an opportunity of seeing typhus fever 
on their ow^n soil ; excepting now and then a few instances, in 
cases of foreigners recently arrived from Britain. Three such 
cases fell under my own observation during the summer of 1842. 
In one of them, a boy thirteen years of age, the disease was 
clearly and strongly marked. For the first w^eek, there were great 
stupor, delirium, a dark suffusion of the eyes ; the skin was fuli- 
ginous, congested, and covered with a dusky, mottled, efflor- 
escence. The whole aspect of the patient struck his physician. 
Dr. Dalton, as being very different from that which is presented 



204 TYPHUS FEVER. 

in our every day typhoid fever; and upon inquiry, it was ascer- 
tained that the lad had recently arrived in the barque Bariow, 
from Greenock, and that there had been seme forty or fifty cases 
of fever, and several deaths, onboard the ship, during her passage. 
The other two patients had recently arrived in the Eutaw, from 
Liverpool, and were received into the Massachusetts General Hos- 
pital. In both of them, there was a very abundant, diffuse, ill-de- 
fined eruption, of a dusky red color, very partially disappearing on 
pressure, or not at all. Some of the spots, especially upon the 
extremities, were petechial. In other respects, the symptoms 
corresponded very closely with those exhibited in the boy from 
the Barlow. The cerebral disturbance was marked in all, and 
the abdominal symptoms were either Terj slight or wanting. A 
continued fever, which seems to have been evidently contagious, 
prevailed in the Boston Alms House, in 1817. The account of 
it, however, which was published in the New England Journal of 
Medicine and Surgery, for April, 1818, by Dr. John B. Brown, is 
not sufficiently detailed and particular, to enable us to decide 
whether it was typhus or typhoid fever. ]Many cases are annually 
received into the hospitals of our large cities, especially those of 
New York, from the British emigrant vessels. The ship Eutaw 
arrived at New York, March 6th, 1842, forty-two days from Liver- 
pool, with about two hundred passengers, mostly Irish, seventy of 
•whom were sick with typhus on her arrival. Amongst these, 
there were eight deaths. The barque Barlow arrived at New 
York from Greenock, May 15th, 1842, after a passage of forty 
days, with nearly fifty typhus patients ; there having been three 
deaths before her arrival. These are instances of what occurs 
nearly every year.^ In August, 1840, twenty-one cases of t}-phus 
were admitted, from a single vessel, into the Boston Alms House. 
Four of the cases were fatal. Dr. Butler informs me, that the 
dullness of the mind, deafness, stupor, suffusion of the eyes, and 
dinginess of the skin, were amongst the most prominent symp- 
toms. The bowels were usually torpid, and there was slight 
meteorism in only two or three cases. Dr. Doane, physician at 
the New York quarantine establishment, informs me, that amongst 

* The number of these cases during the present year, lS47.has been immensely 
greater than it ever was before. The hospitals of most of the commercial cities from 
the St. Lawrence to New Orleans have been crowded with tj-phus patients, coming 
mostly in emigrant ships from Scotland, England, and Ireland. 



CAUSES.— LOCALITY. 205 

the most striking and constant phenomena of the disease, he has 
noticed the injection of the eyes, the fuliginous aspect of the skin, 
and deafness. Diarrhoea is rare, and the alvine discharges, when 
procured by medicine, are dark-colored, and offensive. The evi- 
dences of the contagious character of the disease, observed by 
Dr. Doane, are very positive ; during his connection with the 
institution, a period of about three years, no less than fifteen or 
sixteen individuals, connected with the hospital, having died with 
typhus fever, which had been contracted from the emigrant pa- 
tients. 

The disease, which w^as commonly called spotted fever, and 
which prevailed in many parts of New England, principally be- 
tween the years 1807, and 1816, is supposed by some writers to 
have been the true typhus fever. Dr. Gerhard says, that it was 
similar in its nature to the British typhus. Dr. James Jackson 
thinks, that it was a different disease. It is very certain, that in 
many important particulars, it bore a very striking resemblance to 
true typhus. This resemblance is noticed by most WTiters upon 
the disease. Dr. Elisha North called it a new petechial malignant 
typhus. Dr. Hale, of Boston, whose description of the disease, 
as it prevailed at Gardiner, Maine, in the spring of 1814, is the 
fullest and best that has been published, regards it as a congest- 
ive fever. He speaks of the many points of resemblance w^hich 
exist between it and Dr. Armstrong's typhus ; but he says, also, 
that there are many strong points of difference between the two 
diseases. It is not easy, at the present day, upon such evidence 
as we possess, to decide w^ith any confidence, upon the precise 
character of the spotted fever of New England. Without going 
any farther into the consideration of this question here, I will 
merely observe, that an examination of most of the records that 
have been left us of this disease, has induced me to believe, that 
it belongs to that class of new and more or less temporary epide- 
mics, — each having its peculiar character, marked by its peculiar 
phenomena, and depending upon new^ and peculiar combinations 
of unknown morbific influences, — which have always, from time 
to time, made their appearance, rather than to the class of esta- 
blished and permanent maladies. 

Dr. Gerhard thinks, that some of the epidemics which overran 
the Middle States, between the years 1812, and 1820, were of 
typhus fever ; and that it w^as of this disease, that three distin- 



206 TYPHUS FEVER. 

guished professors in the University of PennsylTania — Rusli,Wis- 
tar, and Dorsev — died. He says, that Dr. Parrish, one of the 
most experienced physicians of Philadelphia, "who practised very 
extensively amongst all classes of inhabitants, in the winter of 
1812-13, when he saw some of the cases at the Philadelphia 
Hospital, in 1836, immediately recognized their identity with those 
of the former epidemic. A pupil of Dr. Gerhard's from North 
Carolina, informed him, that he had witnessed a similar fever 
amongst the negroes. It seemed to he contagious, and from the 
absolute disrecrard of cleanliness and the crowded state of the 
negro cabins, it frequently spread extensively. It is hardly ne- 
cessary to say, that these and similar opinions are to be received 
with a good deal of caution ; and that the extent and frequency 
of the prevalence of true typhus fever in the United States can 
only be determined by the accurate and continued observations of 
the future. Upon this question, as upon so many others con- 
nected with epidemic disease, the past sheds but a confused and 
uncertain light. 

It is very clear, that for the last twenty-five years, at least, true 
typhus fever has been almost or entirely unknown in France. In 
the years 1813, and 1814, there appeared at Paris a severe epi- 
demic fever, which was first noticed amongst the troops who re- 
turned from Napoleon's campaigns in Germany, and the east of 
France ; and which afterwards spread amongst the inhabitants of 
Paris, and other large cities, and was ever^'where extremely fatal. 
This epidemic, Dr. Gerhard is disposed to believe, was typhus 
fever, although Louis, Chomel, and other French physicians, who 
observed it, are inclined to regard it as identical with their pre- 
vailing typhoid fever, or dothinenteritis. 

A writer in the October number of the British and Foreign Me- 
dical Review, for 1841, thinks, that the fever which devastated 
Italy, in 1816 and 1817, was identical tvith the typhus of Great 
Britain. 

The fixed and constant residence of typhus fever is to be found 
in the British Islands. The mud cabins of Ireland, and the damp 
dark cellars of the cities of Great Britain, are its trae habitat. 
These are its perpetual lurkinof places, and here it is always to 
be found. The terms, Irish tj-phus, and British typhus, have, 
indeed, come to be its most distinctive appellations. 

The number of deaths, in England, except the metropolis, from 



CAUSES.— SEASON, WEATHER, ETC. 207 

typhus, in 1841, was 13,795; of these, 6,618 were males, and 
7,077 females. The number in 1842 was 15,027 ; of these, 7,056 
were males, and 7,971 females.^ 

According to the Report of the Registrar-General, there is no 
marked difference in the mortality from typhus in town and coun- 
try districts in England ; the annual mortality to one million 
living, in 1841, being for the town districts, 908; and for the 
country districts, 929. 

John Hunter says he never met with the disease in the West 
Indies.^ 

Sec. II. — Season, Weather, 8fc. Typhus fever prevails at all 
seasons of the year. Several of the Irish writers have remarked, 
in general terms, that the disease is found to prevail most exten- 
sively, during the early part of summer. It seems probable, 
however, from extensive and accurate researches, that the differ- 
ence in the extent to which the disease prevails, in the different 
seasons of the year, is not very great. Illustrative of this point, 
so far as a single locality is concerned, I copy the following table 
from Dr. Mateer's statistics of fever, during a period of eighteen 
years at the Belfast Fever Hospital. It shows the aggregate 
number of admissions into the hospital, arranged according to the 
four seasons, for this long and continuous series of years, with the 
average rate of mortality for the several seasons. 

Summer 2596 1 to 17|y for Summer. 

Autumn 2482 1 to 15^| for Autumn. 

Winter 2359 1 to I42V for Winter. 

Spring 2412 1 to 13f j for Spring. 

It appears, from this table, that the influence of season in favor- 
ing the prevalence of typhus fever, is small. It appears, also, 
that the rate of mortality is highest in the spring and winter.^ 

The deaths from typhus, in England, in 1841, were distributed 
in the following manner through the quarterly periods of the year; 
in spring, 4,218 ; in summer, 3,498 ; in autumn, 3,197; in winter, 
3,941."* In the following year, 1842, there was a wider difference ; 
the deaths in spring, being 3,910; in summer, 3,480; in autumn, 
3,680; and in winter, 5,131.^ 



Rep. Reg. Gen. 2 Hunter's Diseases of the Army, p. 83. 

Dub. Journ. of Med. Sci., vol. x. p. 34. * Rep. Reg. Gen., 1843. 

Ibid., 1844. 



208 TYPHUS FEVER. 

As to the effects of the sensible qualities and changes of the 
weather, nothing very positive seems to have been ascertained. 
These effects are doubted by some observers, and not agreed upon 
by others, who admit their existence. Thus Dr. Percival says ; — 
" It has long been observed, that protracted dry weather is pecu- 
liarly productive of fever in Dublin;" and Dr. Cheyne says, — 
" more than thirty years ago, it was remarked by a very eminent 
physician, the late Dr. Quin, that wet and cold summers always 
proved healthy ones in Dublin." Still, the same excellent ob- 
server informs us, that the summers of 1816, and 1817, when 
fever was extensively prevalent, were wet, cloudy, and cold ; and 
Dr. Barker makes the following rem ark, — "the state of the weather, 
as to moisture, has been said to have affected the progress of this 
fever in other parts of Ireland. I cannot say, that I have observed 
this in Dublin, although I have kept a register of the weather dur- 
ing several years past."^ Dr. Henderson, in his account of the 
epidemic at Edinburgh, in 1838, and 1839, says, that cold weather 
had commonly the effect of increasing the number of admissions 
into the Infirmary, which declined again when the temperature 
was moderate.^ Dr. James Arrott, of Dundee, remarks, that all 
his inquiries tend to prove that great vicissitudes of the weather, 
and especially that great degrees of cold and wet, are powerful 
causes of typhus.^ The great epidemic of 1741, was coincident 
with two very severe winters, and two very dry summers, one 
of which was very hot; that of 1817 was attended by mild win- 
ters, and very wet and cool summers. Rutty says, — "whenever 
we observe the usual harmony and proportion of the winds and 
attendant weather to vary much, we may expect an unhealthy 
season."^ 

Sec. III. — Contagion. Typhus fever has been almost univer- 
sally regarded, by those physicians who have enjoyed the best and 
most extensive opportunities for observing it, as a disease, capa^ 
ble of direct transmission, from one individual to another, by means 
of contagion. Amongst others, of the older British writers, who 
maintained this opinion, may be mentioned Willis, Huxham, 
Grant, and Pringle ; and amongst the moderns, there are but few 

* Trans, of Phys. of Ireland, vol. ii. p. 527. 

2 Edin. Med. and Surg. Journal, Oct. 1839. a Ibid, vol. li. p. 127. 

4 Harty's Sketch, p. 142. 



CAUSES.— CONTAGION. 209 

who dissent from it. Different observers differ, it is true, amongst 
themselves, in regard to the extent, to which the principle of con- 
tagion operates, in the propagation of the disease, and in regard 
to some other points connected with this subject; but they very 
generally admit the fundamental fact, of its contagious transmis- 
sibility. Dr. O'Brien, in a Dublin Fever Hospital Report, for 
1819, in allusion to this matter, says, — "that the skepticism of 
one or two individuals has gone so far as to deny the existence of 
contagion altogether in the fevers of our climate," but that the 
opinion is so singular, and so contrary to the general sense of 
mankind, that little attention has been deservedly paid to it. 

The extreme doctrine in regard to the contagiousness of typhus 
fever is, that the disease is exclusively, and invariably, the pi'oduct 
of contagion; — that it never arises from the action of other causes 
alone; that it is never spontaneous, as it is called, in its origin; 
that it resembles, in this respect, small-pox, and not scarlatina. 
This opinion is not generally entertained, and must have been 
always the result rather of philosophizing, than of observing; for, 
certainly, the evidence of direct observation is altogether against 
this exclusive opinion. It is easy to see, that the accurate settle- 
ment of a question of this character is exceedingly difficult ; and 
that where a considerable number and variety of influences are 
or may be acting together in the production of disease, it must be 
often quite impossible to determine, with any degree of certainty, 
the actual and comparative agency of each. One thing, however, 
in regard to the present matter, is perfectly clear; and that is, 
that in very many cases, there is no positive evidence, whatever, 
of the action of contagion. Dr. Edward Percival says, — " having 
made it my business to inquire into the origin of most cases of 
fever, that w^ere admitted to the Hardwicke Hospital, during 
several years, I found the results to point less frequently and pre- 
cisely to a contagious source, than I should have anticipated."^ 
Dr. F. Barker observes, that of ninety patients in the Cork Street 
Fever Hospital, in October, 1817, of whom minute inquiry was 
made, in relation to this point, only twenty-four could refer their 
cases to the effects of contagion.^ From a pretty careful, and 
certainly an unprejudiced, examination of this subject, in the ob- 
servations and opinions of British writers, I think w^e may look 

• Trans, of Phys. of Ireland, vol. i. p. 287, 2 Jbij.^ vol. ii. p. 530. 

14 



21Q TYPHUS FEVER. 

HDon k as well s^tt^that the modbid actions constitiituig typhus 
ferer aie capable of generatiDg in the bodj a prason, which, 
when ctmceutratedy and aided in its operatiim bj h^wtmng cir- 
cmnslaiicesy irill pxoduce tbe same disease in peiaons exposed to 
its influence. We maj consider it, also, as not less certain, that 
iJie same poison may be generated by other agencies ; amongst 
die most actire of -which seem to be the crowding tc^^er in 
dose, nnyentilated, apartments, amidst accnmnlated personal 
filth, of the wretched and anfileiing pow. I shall state the more 
obinbos groonds upon which these condu^ns rest. 

Dr. CHBrien, in his Ckxk Street Ferer Hospital Rep(st for 1816, 
states, that of nine ^ystcians, who had been permanently attached 
to the institution, fire had had ihe disease, in two of whom it 
pioTed fiitaL Of the fiior who escs^>ed, two had had contagious 
ferer be^se theor connediion with the hospital. AH the nurses, 
employed in tiie hospital, had sofQsred &om the disease.^ Of the 
medical men connected with the Sondi Fever Asylum, at Cork, 
daring Ae epdemic of 1817, 1818, and 1819, seven physicians, 
the apothecary, and his apprentices, contracted severe fevers. 
Two of the physicians died. Nearly aU the other persons, con- 
nected widi the hospital, and who, firom the nature of their occu- 
pations^ were in frequent and dose comronnication with the sick, 
—the hair colter, the porters, the nnrses, — were attacked with the 
fever .^ At the Hardwicke Fever Hospital, Dublin, in 1S16, all 
the nnrses and other ri'sidents in the hospital, amounting to twenty- 
three persons, escaped the disease. Dr. Cheyne attributes this 
exemplicm to the cleanliness and free ventilation of the institu- 
tion.^ Still, it spears, that in the following year, many of the 
ol&cecs of the same establishment caught the fever. Amnrigst 
them, were eig^ cr- nine medical gentlemen, the steward, aU the 
servants, in succession, whose business it was to remove the 
clothes ci the patients npon their first admis^n, and most of the 



The opinions of fte celebrated Dr. Armstrong, upon this point 
in the history of tyi^us, are well known. In the early part of his 
life he adopted the popular doctrine of the contagious nature of 
the disease. In a paper on the origin, nature, and prevention of 
typhus lever, cmnmunicated to the Medical Intelligencer in May 

1 Tiai&arFfa^of]iefaDd,TaL£.pL4S5L * Iha, toL iii. p. 224. 

> IMInHKp.Be]ntts,^oLLp.§3u « ]{^ tqL ii p. 53. 



CAUSES.— CONTAGION. 211 

1822, he expresses some doubts, as to the correctness of his former 
opinions in relation to this question. His skepticism in regard to 
the contagious character of typhus, under any circumstances, con- 
tinued to increase with his advancing years, and experience ; and 
in a lecture on the disease, published in 1825, although he does 
not deny the possibility of the transmission of typhus by contagion, 
he is unwilling to admit the existence of any positive evidence, 
that such is ever the case. It ought, however, to be stated here, 
that Dr. Armstrong's conclusions upon this subject were evidently 
somewhat influenced by his singular doctrine of the essential iden- 
tity of intermittent, remittent, and typhus fevers; and of their 
dependence upon a single common cause. ^ 

It may be added, in connection with this subject, that nothing 
is more common, during the prevalence of typhus fever, than for 
a considerable number of individuals, residing in the same room, 
to be successively attacked with the disease. In many instances, 
all the members of a large family, and even of several families, 
inhabitants of the same house, have, one after another, become its 
subjects. This common occurrence is noticed by most of the 
Irish writers upon fever. Of 9,588 patients received into the 
Belfast Fever Hospital, from 1818, to 1835,2,342 came in single 
cases; while 7,246 came in numbers of two or more from the 
same family. They came from 1,856 families, thus giving an 
average of nearly four patients to a family.^ One of the circum- 
stances which early attracted the attention of Dr. Gerhard, in the 
Philadelphia typhus of 1836, was the fact, that the patients came 
in groups, and several from the same house. Amongst the first 
admitted into the hospital, w^ere seven negroes, the entire popula- 
tion of a cellar, in the lower part of the city. This occurrence of 
several cases in the same house has been but very rarely observed 
amongst the comfortable and rich classes in Ireland. Under these 
circumstances, the fever has not usually extended to more than a 
single member of a family. 

The latent period of the contagious principle has not been accu- 
rately ascertained. It is probably different in different cases. Dr. 
Barker says, that in many instances, it seems to extend to two or 

' ^Memoir of the Life and Medical Opinions of John Armstrong, by Francis Boott,. 
vol. i. pp. 149-171. 

2 Dub. Jour, of Med. Sci., vol. x. p. 35. 



212 TYPHUS FEVER. 

three weeks. Dr. Perry, of Glasgow, intimates, incidentally, in his 
letter on typhus fever, published in the Dublin Journal of Medical 
Science, for January, 1837, that the disease rarely, if ever, makes 
its attack, in less than eight days from the time of exposure. 
The same gentleman says, that numerous observations and ex- 
periments have satisfied him, that typhus fever does not commu- 
nicate its contagious principle, before the ninth day of the disease, 
and perhaps not till a later period. Many very striking instances 
are recorded, however, by different writers, in which the disease 
seems to have been directly and immediately received from a 
patient laboring under it, and to have instantaneously manifested 
itself. Dr. Henry Marsh, of Dublin, in an admirable paper upon 
the origin and latent period of fever, published in volume iv. of 
the Dublin Hospital Reports, enumerates twenty cases of this sort. 
He says, that they constitute a few, amongst many facts of the 
same kind, which he has been able to collect, and that every day's 
observation adds to their number. In most of these instances, 
the persons, many of whom were nurses or physicians, while in 
the act of rendering some service to the sick, which exposed them 
to the strong, offensive odor arising from the beds or bodies of the 
patients, were immediately seized with headache, great prostra- 
tion of strength, and with nausea, perhaps, or rigors; and these 
symptoms were soon followed by the full development of the dis- 
ease; in many of which cases it proved fatal. He mentions the 
deaths of three physicans. Dr. Crawford, Dr. James Clarke, and 
Dr. Waring, under such circumstances. Two cases of a similar 
kind are reported by Dr. Gerhard, in his account of the Phila- 
delphia typhus of 1836. He says, — " the nurse was shaving a 
man, who died in a few hours after his entrance ; he inhaled his 
breath, which had a nauseous taste, and in an hour afterwards 
was taken with nausea, cephalalgia, and ringing in the ears. 
From that moment, the attack of fever began, and assumed a 
severe character. The assistant was supporting another patient, 
who died soon afterwards; he felt the pungent sweat upon his 
skin, and was taken immediately with the symptoms of typhus." 
It would be easy to multiply, and that to a great extent, similar 
examples. Sir John Pringle says of the jail fever, — "I have ob- 
served some instances of a high degree of contagion attending it; 
but the common course of the infection is slow, and catching to 



CAUSES.— CONTAGION. 213 

those chiefly who are constantly confined to the bad air, such as 
the sick in hospitals, and their nurses, and prisoners in jails. "^ 

In connection with this subject it should be stated, that even 
during the prevalence of very general epidemics, certain circum- 
scribed localities sometimes are nearly or quite exempt from the 
disease. Thus, in the House of Industry at Cork, and in the 
Foundling Hospital of that city, in 1817, 1818, and 1819, the 
disease scarcely showed itself, when very prevalent amongst the 
inhabitants in general. The jail at Cork also remained free at 
the same time; and in the Marine School, and the Royal Hibernia 
Military School, in Dublin, there were but few^ cases. ^ The oc- 
casional exemption of the inmates of these and similar institutions 
has been generally attributed to their seclusion, and consequent 
freedom from exposure to contagion. 

Another important quality of the contagious poison seems to be 
very well ascertained, — to wit, — that, as a general rule, it must be 
concentrated and abundant, so to speak, in order to excite the 
disease. A few cases in a large, cleanly, and well ventilated 
ward, do not often communicate the disease to the other occu- 
pants, nor to the medical attendants and nurses. Dr. Christison's 
testimony on this point is very explicit and direct. He says, — ■ 
" The infection of continued fever is for the most part by no means 
virulent. This is contrary to universal prejudice among unpro- 
fessional persons, and to the opinion entertained even by some 
members of the medical profession. But it is nevertheless certain, 
so far as minute observations of several violent epidemics during 
the last tw^enty years can determine the point, that moderate pre- 
cautions w^ill render the infectious atmosphere inert. Cleanliness 
and ventilation wall speedily extinguish any epidemic. For it is 
well ascertained, that fever communicated to an individual in the 
better ranks by attendance on the sick in hospital, is very rarely 
propagated in his own station, or to any of his attendants. Among 
numerous instances knowm to the writer, of young practitioners 
and medical students who have caught fever in the prosecution of 
their practical studies, not a single case has occurred where the 
disease was communicated in their families at home or in their 
lodging houses.'" 

* Dis. of Army, p. 256. 2 Account, etc. By Barker and Cheyne, vol. i. p. 96. 

3 Tweedie's Library of Practical Medicine. I cannot refrain from asking here^ 

in a note, how far this dependence of fever upon a want of cleanliness, and ventila- 



2J4 TYPHUS FEVER. 

Sec . IV. — Epidendc. Tlie entire hisfoiy of typhus fever diows, j 
concIusiTely, tiat it is often Tciy intimatdy dependent npon thatj 
nnknomn iniSuence, or combination of influences, to ^liiich Ihei 
tenn gmfemtc bas been a^pfied. Afier estimating, as nicelj as] 

our means vill enable us to do, liie agency of tbe sereral 
posed causes, exciting and predisposing, of the disease, we 
still unable to account for its general preTalence, during 
periods, and orer more or less extensive f^ions, wilhoat : 
to tlak ancient Lypotbesis of an occult influence, or agent, 
we know not whence, — ^siiether fivHn the eail^ the air, or 
stare, — and ?. : r "~e know not how, in the production of its' 
results. In :„i ::-£z of typhus fever, as of many other diseases,, 
— of scarlatina, of measles, of small-poic, — ^it is evident, that 
dependent of all the drcumstances which are admitted to fax 
its occurrence and its esten^n, there exists, at ceifain times, 
predisposition or tendency to Hie disease, which we are who] 
unable : :': :> or explain. Like the small-pox, and 

scarlet fd--:, :: ~ays present in Ireland; hut at condderabi 
intervals, we fir. rsaang immensely in the extent rf 

prev : ' f : t "57 usually, of fiom one to two 

three T^irs. --.— - --e i-^' ': ; permanent and average 
ard. Several of the great Iris: ::iics have been already 

qnently alluded to. F - : :e inclined to think 

the flagneSy as they "z:= Tompanied the 

great civil wars in Ireland, — :: ElizabeOi's 

and the second, ti - ■ ^^' : : "; : : _ _ ^ ^ 1 — ""ere epid( 

of typhus. Th&rr :/.- ::,:-:.- l:v.::-.zi :: t;:. emics, more 
less complete, in 1'^ i 1709; in 1718, 1719, 1720, 
1721; fiom 1728 to 17: "4" and 1741; in 1762; 

1797 to 1802; in 1817, 1 1 19, and so on. 

Barker and Cheyne estimate the number of cases, during 
epidemic of 1817, 1818, ai»d 1819, at ame mSKum amd a half. 

It is remaiked by Baiker and Oieyne, that the duration of 1 
-demies has, in many instances, been about, two years. This 

ideraaii^cf ^bsse two di^ase^aa^ -w^ awe ^sgw^aoi ^mt^ ^e 

dsj^asef l<et iSiena tij iitg-wlaera i^'phind fe^i^er pfssvails as it a> 
stv^ does Smm^ die beoniiM amd broesEf 

l^dieb 

pf^obsfiianof 




CAUSES.— CROWDING, FILTH, FAMINE, ETC. 215 

the case in 1740 and 1741; in 1800 and 1801; and in 1817, 
1818, and 1819.^ 

Sec. V. — Crowding; Filth; Famine, etc. Amongst the cir- 
cumstances, which, to say the least of them, are very frequently 
associated loith the presence of typhus fever, are the crowding of 
persons together, in dark, damp, and badly ventilated, apartments; 
anxiety ; fatigue ; excesses ; exposure to the inclemencies of the 
Aveather; and scanty and poor food. The real and relative agency 
of these several influences, in the production of the disease, has 
not been very minutely and carefully studied, but there can be 
little doubt, that they are often amongst its most powerful and 
prolific causes. 

The very intimate connection of typhus fever with crowded, ill 
ventilated, and filthy apartments, has been universally admitted. 
This is the pestilence which dogs the footsteps of retreating and 
discomfited armies, and takes up its dwelling in their tents; which 
hides itself within the dark and noisome walls of ancient prisons ; 
which lurks, amidst destitution and vice, in the narrow lanes and 
unlighted cellars of great cities, and which has been, for many 
generations, the perpetual inmate of the low, mud cabins of the 
Irish poor. 

Of jail fever. Sir John Pringle observes, — "This disorder is 
incident to every place, ill-aired and kept dirty ; that is, filled 
with animal steams from foul or diseased bodies. And upon this 
account, jails and military hospitals are most exposed to this kind 
of pestilential infection ; as the first are in a constant state of filth 
and impurity, and the latter are so much filled with the poisonous 
effluvia of sores, mortifications, dysenteric, and other putrid excre- 
ments. I have seen instances of its beginning in a ward, when 
there was no other cause but one of the men having a mortified 
limb."2 

The connection of the great typhus epidemics of Ireland with 
a general scarcity of food has long been noticed. It has been 
estimated, that during the years 1740, and 1741, eighty thousand 
persons died in Ireland, of fever, dysentery, and famine. Dr. 
Rutty, then a practising physician in Dublin, informs us, that " in 
the autumn of 1740, there was a great dearth of provisions inlre- 

* Account, etc., vol. i. p. 133. 2 Pringle's Dis. of the Army, p. 255. 



216 TYPHUS FEVER. 

land, which proceeded ahnost to a famine in winter, the potatoes 
harino- failed, whilst other provisions bore double or treble their 
usual price." A subsequent epidemic of 1800, and 1801, was 
also attended by a great scarcity of provisions. Again, the terri- 
ble epidemic of 1817, 1818, and 1819, was preceded, and during 
a portion of the time at least, and in many places, accompanied, 
by a dreadful deficiency of even the commonest food. There are 
few darker pages in the long, sad annals of Irish poverty and dis- 
ease, than that upon which is written the history of this epidemic.^ 
The crops of 1816 had almost entirely failed, and the same thing 
was true, to a considerable extent, of the following year. Not 
only was a large portion of the grain destroyed by the unfavorable 
weather, but the little that was saved was of a poor quality. 

It would be wrong, however, to attribute this, or any of the pre- 
ceding, epidemics to famine alone. Tj-phus fever is constantly 
present in various parts of Ireland, and it has, more than once, 
extensively prevailed, when the harvests had been good, and food 
unusually abundant. This is only one of many co-operating in- 
fluences, to which the wide-spread prevalence of the disease is to 
be attributed. 

Many of the Irish writers often speak of having seen typhus 
fever occurring several. times in the same individual. Dr. Stoker 
speaks of the poor, as having frequent attacks of fever, in the 
course even of a short life, and thinks that few adults have escaped 
these attacks, although he has no doubt that the succeeding at- 
tacks are milder than the first. Dr. O'Brien, in one of his hos- 
pital reports, says, — " some of the nurses have had the disease 
three or four times." Others have remarked, that a second attack 
of the disease is very rarely witnessed, when the first had been 
severe, or when it had been attended by an abundant eruption. 
And there seems good reason for believing that such is the case. 
Dr. Barker, in his report of the Cork Street Hospital, Dublin, 
states that he has for some time entertained the opinion, that suf- 

1 Let me add, in a note, that many of these othervrise gloomy pages aie made 
radiant and luminous with affecting examples of the patient resignation of the j>oor 
sufferers ,• and of the self-forgetfalness and devotion of the Roman Catholic clergy, 
the physicians, and other benevolent friends of the sick. Few incidents in medical 
biography. are more touching and beautiful than the sketeh, which is given of the 
early death of young Gillichan, of Dundalk, one of the many martjrs to science and 
humanity, whose brief lives shed light and glory on the histor)'- of our art. 



CAUSES.— AGE. 217 

ferers from fever, attended with the petechial eruption, if they are' 
not altogether secured by it from a second attack, are not at least 
so liable to it, as those who have had a fever of the ordinary kind. 
*' Though I have frequently made the inquiry," he adds, " I have 
not found a patient in whom this symptom was distinct, who had 
suffered from the same fever on any former occasion. But, what- 
ever maybe the result of more minute inquiry, it may be asserted, 
that the chances of the recurrence of fever diminish in proportion 
to the continuance and severity of the first attack." Dr. Bracken, 
of Waterford, after quoting the above, says, — " It appears to me 
that this opinion is supported by experience, as well as by reason- 
ing from similar facts. Since I first observed this remark, I have 
kept the subject in view, and, after some attention to it, I have 
not been able to ascertain that more than three persons, out of 
many hundreds, who came within my observation, have had re- 
lapse or recurrence of fever, after being previously affected with 
the symptoms in question."^ Dr. Trotter says, — "During our 
extensive and long experience of the origin, progress, and extinc- 
tion of contagion, in ships, and everywhere else, I have enter- 
tained a strong suspicion, that typhous infection very seldom affects 
a person more than once in a life-time."^ Dr. Perry, of Glasgow, 
in a letter to the editors of the Dublin Journal of Medical Science, 
says, — " I have, for some years, entertained the opinion, founded 
upon an extensive series of observations, that contagious typhus 
is an exanthematous disease, and is subject to all the laws of the 
other exanthemata ; that, as a general rule, it is only taken once 
in a life-time, and that a second attack of typhus does not occur 
more frequently than a second attack of small-pox; and, judging 
from my own experience, less frequently, than a second attack of 
measles, or scarlet fever." 

Sec. VI. — Jige. There is no evidence, that this disease is con- 
fined to any period, or periods, of life. During its prevalence at 
Philadelphia, in 1836, children were rarely attacked by it ; but, 
after childhood, age seemed to exercise little or no influence upon 
the susceptibility to the disease. Amongst the whites, where the 
age could be better ascertained, than amongst the blacks, there 
were as many patients over thirty-five years old, as there were 

* Barker and Cheyne's Account, etc., vol. i. p. 241. 
2 Medecina Nautica, p. 213. 



218 TYPHUS FEVER. 

under this age. Dr. Edward Percival, in his Report on the 
Epidemic Fevers of Dublin, at the Hardwicke Fever Hospital, 
during the years 1813, 1814, and 1815, says, that the disease 
prevailed continually amongst the boys and girls of the Bedford 
Asylum ; characterized by petechise, great failure of strength, a 
turgid countenance, and considerable stupefaction.^ Eleven hun- 
dred of these children were crowded together in a building, ori- 
ginally intended to accommodate only six hundred. Of three 
thousand nine hundred and seventy patients, received into the 
Cork street Hospital, Dublin, in 1817, and 1818, there were, under 
ten years of age, three hundred and sixty-two; from ten to twenty 
years, fourteen hundred and seventy-four; from twenty to thirty 
years, twelve hundred and sixty-five ; from thirty to forty years, 
five hundred and eight; from forty to fifty years, two hundred and 
forty-one; and over fifty years, one hundred and twenty.^ Dr. 
Barker says, that in the course of the epidemic of the above men- 
tioned years, he witnessed the disease in many children, under 
the age of four or five years, and in its most exquisite form, — that 
of petechial fever. It will be found, from extensive observations, 
that a large proportion of the cases of tj'phus fever occur in per- 
sons, who are between the ages of fifteen and thirty years ; but it 
would be very unsafe to infer from this fact anjihing positive 
as to the liability of different ages to the disease, unless we have 
first ascertained the whole number of persons, of these different 
ages, exposed to the causes of the fever. From not attending to 
this and other circumstances in these calculations, — from not 
taking into account all the elements of the problem to be solved, — 
many writers have lost themselves on what Dr. Arrott, of Dundee, 
calls the ^'quicksands of false arithmetic. "^^ 

The average age of forty-seven patients, in whom the disease 
proved fatal, at the Royal Infirmary of Edinburgh, in 1 838 and 
1839, was thirty-five years and a half, nearly.^ 

Sec. mi. — Sex. The influence of sex in predisposing to 
typhus fever is not very great. It has been generally remarked 
by Irish observers, that the disease is somewhat more common 
amongst females, than it is amongst males. This fact may be in 
part, perhaps entirely, accounted for, by the more constant expo- 

' Trans, of Phys. of Ireland, vol. i. p. 2SS. 2 Ibid., vol. ii. p. 533. 

3 Ed. Med. and Surg. Journ.. Oct 1S39. 



CAUSES.— RECENCY OF RESIDENCE. 219 

sure of the females to many of the most active causes of the dis- 
ease. From Dr. Mateer's statistics, it appears, that of 9588 
patients admitted into the Belfast Fever Hospital between May, 
1813, and May, 1835, inclusive, 5130 were females, and 4458 
■svere males. Dr. Harty gives a table of the admissions, and 
deaths of the two sexes, at some of the principal hospitals of Ire- 
land, from 1817 to 1819. The number of males admitted w^as 
32,144; the number of females 34,398. The male mortality w^as 
one in 19.40; the female, one in 24.75.^ In connection with this 
subject. Dr. Harty remarks, that, "though it is well ascertained 
that the epidemic spared neither age, sex, nor condition, and that 
all were indiscriminately exposed to its attacks; it is yet certain 
that there were particular periods of the epidemic season, during 
some of which, children, during others, adult females, and during 
others, adult males, predominated in number."^ 

Sec. VIII. — Recency of Residence. New residents in any given 
locality seem to be somewhat more liable to typhus, than others; 
although this circumstance has so little influence, that it has not 
been often spoken of by British waiters. According to a table 
published by Dr. Davidson, of five hundred and sixty-eight patients 
with typhus, admitted into the Glasgow Fever Hospital, in 1838, 
and 1839, one hundred and seventy-six, or one-third, nearly, 
were natives of the city ; one hundred and ten had been residents 
less than six months ; fifty-five, from six months to a year ; ninety- 
seven from one year to five ; and one hundred and thirty, from five 
years to twenty and upwards. Thus more than half of the w^hole 
number had lived in the city five years or upwards.^ 

' Historic Sketch, etc., p. 29. 2 Ibid., p. 31. 

' Dunglison's Medical Library. 



220 



CHAPTER V. 

VARIETIES AND FORMS. 

The most common varieties of tj^hus fever are such as de- 
pend upon different degrees of severity, and such as are more or 
less constantly connected with the different seasons of the year. 
The proportion of mild to grave cases varies considerably under 
different circumstances, but it is almost always very great. Cases 
of all degrees of intensity, from the mildest to the most severe, 
and malignant, just as happens so frequently with scarlatina, and 
small-pox, are often found together, under the same circumstances, 
and apparently depending upon similar causes. 

During the w^inter and spring, the disease is more likely to be 
seriously complicated with pulmonic affections. In the summer, 
and autumn, it is frequently associated with gastro-intestinal irri- 
tation. The disease, in certain places, and for a limited period 
of time, is occasionally marked by certain peculiarities. Dr. John 
Cheyne remarks, that he never witnessed continued fever, with so 
many inflammatory symptoms, as in the spring and summer of 
1816, at Dublin; and that the blood was sizy in nearly one-half 
of the patients who were blooded. In August, and September, 
the cases were often complicated with dysentery, and with symp- 
toms of gastro-hepatic derangement. A distressing nausea was 
common, with a bitter or foul taste, and a yellow tongue. After 
this period, the fever became more severe in its character, and 
was frequently complicated with an inflammatory state of the 
bowels.-^ In December, and the following January, many cases 
were attended with inflammation of the bronchial mucous mem- 
brane. The same writer says, that of one hundred and seventy- 
five patients, admitted into two wards of the Hardwicke Hospital, 
during the months of April, May, and June, 1818, at least three- 
fourths had cough, with pains, or stitch, oppression in the chest, 

' Dub. Hos. Rep., vol. i, p. 15, et. seq. 



VARIETIES AND FORMS. 221 

and quickened respiration."^ But these varieties are in no degree 
more numerous, or more important, than those which are observed 
in the history of all epidemic diseases. Certain individual symp- 
toms, or phenomena, may be frequent at one time and place, and 
rare at another. The occurrence of epistaxis, for instance, or of 
relapses, or of some consecutive affection, may be much more 
common, in one season, than in another. Dr. John Cheyne says 
of the fever at Dublin in 1816, — "relapses, which rarely occurred 
in summer, were uncommonly frequent in winter." 

During the years 1843, and 1844, there prevailed very exten- 
sively at Edinburgh, a form of fever marked by such strong pecu- 
liarities, as to excite some question as to its true character. Dr. 
Alison believed it to be specifically distinct from typhus. A very 
elaborate history of the disease has been published by Dr. Halli- 
day Douglas, in the Northern Journal of Medicine. It was gene- 
rally sudden in its attack, and rapid in its progress. One of its 
most striking peculiarities consisted in its tendency to terminate 
suddenly, after a certain period, by a critical evacuation, — com- 
monly by sweating, — and after an apyrectic interval to relapse. 
This sometimes happened twice. Of one hundred and twenty- 
one cases, admitted into the Edinburgh Royal Infirmary during 
the primary attack, the period of the first crisis was ascertained 
in eighty-three. It occurred on the fourth day, in two ; on the 
fifth day, in twelve; on the sixth day, in twenty-five; on the 
seventh day, in twenty-seven; on the eighth day, in nine; on the 
ninth day, in four; and on the tenth day, in four. Only six of 
the remaining thirty-eight are said to have recovered gradually, 
and not by an abrupt crisis. The crisis was, in most instances, 
preceded by a rigor or chilliness; and in all but two cases, ac- 
companied by a sweat more or less profuse, lasting generally for 
a few hours, in a few cases, for two or three days. Sometimes, 
during the sweat, the pulse increased in frequency, but not always. 
The apyrexial period, or intermission w^as quite complete in all 
but fifteen cases. Its usual duration was from five to seven days. 
The relapse was almost universal. Of one hundred and forty 
cases, in which the time of its occurrence was ascertained, it 
took place between the ninth and thirteenth day of the fever, in 
seventeen ; on the thirteenth, fourteenth, and fifteenth days, in 

' Dub. Hosp. Rep., vol. i.-p. 15, et seq. 



222 TYPHUS FEVER. 

eighty-one; and subsequent to the fifteenth day, in forty-two. 
The relapse was generally ushered in by a rigor, and followed by 
febrile symptoms, less urgent, however, and of shorter duration 
than in the primary attack. This relapse usually terminated by 
a second crisis, between the second and the fifth day, inclusive, 
from its commencement. In eleven cases, there was a second 
relapse, occurring at different periods from the eighteenth to the 
thirty-sixth day of the disease. The duration of the second re- 
lapse varied from one to five days. The access was generally 
accompanied by epigastric distress, and bilious vomiting. In a 
certain proportion of cases the patients became jaundiced. Dr. 
Douglas says the frequency of this occurrence has been exag- 
gerated. He met with it in only twenty-nine of two hundred 
and twenty cases. The epidemic was marked by some other 
minor peculiarities. It was clearly enough, I think, ordinary 
British typhus, wearing the peculiar livery of a temporary epi- 
demic. It is strange that it should have been regarded, as it 
seems to have been by some of the Edinburgh physicians, as 
identical with the yellow fever of hot climates. 

I have said nothing about the old Cullenian division of con- 
tinued fever into synocha, synochus, and typhus, for the sufficient 
reasons, that this division is altogether arbitrary and conventional; 
and that although some few of its illustrious author's countrymen 
still cling to it, it is very generally and very properly abandoned. 



223 



CHAPTER VI. 

DURATION AND MARCH. 

Sec. I. — Duration. The duration of typhus fever varies very 
considerably, in different cases, and under different circumstances. 
Death often takes place at an earlier period, than ever happens 
in typhoid fever. Dr. O'Brien says, that death is not unfrequent, 
on the fifth or sixth day of the disease. Dr. Pickels remarks, that 
the disease, when fatal, rarely exceeded the eleventh, or thirteenth, 
day, and in many cases, that it was much shorter. Dr. Edward 
Percival noticed, that death was most common between the 
eleventh, and seventeenth, days. Dr. Bracken of Munster, in a 
communication to Drs. Barker, and Cheyne, says, that in the epi- 
demic of 1817, 1818, and 1819, the greatest number of deaths 
took place on the ninth day; and then, successively, on the tenth, 
twelfth, eleventh, seventh, and eighth. 

The statements of most of the Irish writers, in regard to the 
average duration of the disease, are not, I think, to be very con- 
fidently relied upon. They do not tell us, in what manner the 
duration was estimated, nor what mode was adopted for fixing 
the commencement, and the termination, of the cases. Dr. Lyne, 
of Fralee, says, that in the epidemic of 1817, 1818, and 1819, 
the duration of the disease ranged from five to twenty days; the 
average period being fourteen days.^ Dr. Bracken, of Munster, 
estimates the average duration in the same epidemic, at nine 
days, before puberty, and at fourteen days, for adults.^ Dr. 
Pickels, in his report of the South Fever Asylum, at Cork, for 
1817, 1818, and 1819, says, that of fifty-nine cases, taken in 
succession, under the age of sixteen years, and which recovered, 
thirty-seven did not exceed the tenth day, and twenty-two did ; 
and that of sixty cases, over the age of sixteen, which recovered, 
nine did not exceed the tenth day, and fifty-one did.^ The testi- 

' Barker and Cheyne's Account, etc., vol. i. p. 154. 2 Ibid., vol. i. p. 304. 

3 Trans, of Pliys. of Ireland, vol. iii. p. 203. 



224 TTPHirS FEVER. 

monj of th.e Irisk observers is Tery unanimous as to the shorter 
dTiration of the disease, amongst the young, than amongst adults. 
It is less, also, in mild, than it is in grave cases. Dr. Stoker 
found at the Cork Street Hospital, Dublin, in the summer of 1818, 
that of four hundred and seventy-one cases, mostly mild, nearly 
three-fourths terminated on, or before, the seventh day. 

Dr. Mateer, of Belfast, makes the average duration of typhus 
fever considerably greater, than most of the British writers have 
made it. This may depend in part upon his more accurate in- 
vestioration of this snbject, and in part upon his adopting a difir:- 
ent mode of fixing the termination of the disease. His calculation 
is founded upon 11,209 patients, treated, during a series of nearly 
twenty years, in the Belfast Fever Hospital. He found, that the 
average period, during which the patients remained in the hos- 
pital, under the disease, was about twenty-two day?: and that 
they had, on an average, been ill about seven days, ': t:::^ :eingi 
brought to the hospital. This would give to the cases a mean 
duration of twenty-nine days. It is important, however, to ob-| 
serve, that the termination of this average period is fixed, not at 
the commencement of convalescence, but at the re-establishment | 
of health. The mean time at which, even according to Dr. 
3Iateer's calculations, the disease, in cases which terminate] 
favorably, reaches its highest degree of severity, and begins to 
retrograde towards recovery, is about ih^ fourteenth day. "Dur-j 
ing these twenty-nine days," he says, "the complaint progresses 
for a definite period, till a certain point of intensity is attained ; 
after which, if a fatal event have not taken place, the symptoms] 
drminish in severity. This point, commonly termed crisis, oc< 
at some fixed time. In one hundred consecutive cases, carefuDjI 
noted tor this purpose, it was found, on a mean calculation, that j 
the fourteenth day was that on which the crisis took place, otI 
nearly about one half the time which, as we have already seen,1 
the whole course of fever takes up in each individual. So that i1 
would seem to be proved by extensive observatioii, diat the dasA 
ease takes up one half of twenty- nine days to pn^jress, and 
remainder to retrograde ; or, in other words, that the periods 
increment, and of decrement, in the intensity of the symptoms iai 
fever, are equal and proportional."^ Dr. Alexander P. Stewart 

• JMa. Jaw. Med. Sd- voL i. p. 41. 



DURATION AND MARCH.— CRISES. 225 

says, that the mean duration of typhus fever at Glasgow, calcu- 
lated from the results of many thousand cases, during successive 
years, is about twenty-one days.^ Dr. Henderson says, that the 
average date of commencing convalescence, at the Royal Infirmary 
of Edinburgh, in 1838, and 1839, was the thirteenth day. The 
average period at which death took place, calculated by Dr. Reid 
from one hundred and forty-three cases, w^as between the twelfth 
and the thirteenth day.^ 

Sec. II. — Crises. Many of the Irish writers on typhus fever 
allege, that in very frequent instances, the disease terminates in 
what has been called a crisis. That the commencement of con- 
valescence, in this as well as in many other diseases, should be 
formally and pretty clearly marked, by certain phenomena of a 
decided character, is what we can easily understand, and what 
we frequently see. The coming on, after its long absence, of 
quiet and protracted sleep; accompanied, as this grateful and re- 
freshing visitation often is, with a diminution in the frequency of the 
pulse, a restoration of the integrity of the mind, and a change in 
the state of the skin, from an arid heat to a warm, gentle, and 
equable moisture, most certainly indicates a great and radical re- 
volution in the condition of the system, which may well be called a 
crisis. But something more than this formal and obvious change 
in the state of the living tissues, from a morbid to a healthy action, 
is often meant, I think, by writers who speak of these crises in 
typhus, and other, fevers. They tell us of a violent struggle in 
the suffering economy, which precedes and accompanies the tran- 
sition of the functions from their diseased and perturbed action 
to their natural and easy play. They speak, as though the re- 
cuperative powers of the system, almost worn out, or overcome, 
by the morbific influences which have obtained possession of the 
organs, had now gathered up and concentrated all their remaining 
energies; had now taken their desperate and final stand against 
the further inroads and ravages of disease ; and as though the 
perturbation resulting from this conflict constituted the critical 
struggle, terminating, as the case may be, either in recovery, or 
m death. This is neither an unfair nor an exaggerated statement 
of the views of these observers. Thus, Dr. Percival, in his 

* Edin. Med. and Surg. Jour., Oct. 1840. 

2 Edinburgh Med. and Surg. Journal, Oct. 1839, and Aug. 1842. 

15 



226 TYPHUS FEVER. 

Hardwicke Fever Hospital Report, for 1813, 1814, and 1815, 
says : — " The critical period vv^as often a scene of severe struggle, 
the issue of which was for many hours doubtful. An obscure 
rigor would set in on the eve of the fourteenth day, or later ; de- 
lirium and jactitation would increase, the extremities become cold, 
respiration, hurried, and oppressed; the countenance, pale, and 
anxious ; and the pulse, by its frequency, smallness, and irregu- 
larity, scarcely numerable. The patient would often moan loudly, 
from pains referred by him to the bones of his back, and limbs. 
This struggle usually increased for some hours, and then subsided 
into relief, or the gradual extinction of life." ^ Dr. Percival, also, ex- 
presses the opinion, that the term of convalescence was lengthened, 
or shortened, in proportion as the crisis was fully, or obscurely 
formed. Dr. Cheyne, in his Hospital Reports, makes very frequent 
mention of crises, marked by rigors succeeded by sweats. He 
noticed this termination of the fever much oftener, during some 
periods, than in others. Thus, he says, that between the 12th and 
the last of May, 1817, amongst fifty-nine patients admitted into 
the Hardwicke Hospital, there were twenty instances of this form 
of critical resolution, although, previous to this time, he had good 
reason to think, that such a termination was exceedingly rare. "The 
rigor of crisis," as Dr. Cheyne calls it, he says rarely lasts long; 
perhaps only a few minutes, perhaps half an hour, or an hour. 
Another form of crisis is thus characterized by the same accurate 
observer: — "A state of restlessness and anxiety, with flushing of 
the face, rapid pulse, frequent, laborious breathing, and increased 
heat of the surface, with great distress at the pit of the stomach 
from heat, tenderness, or pain ; which distress was not unfrequently 
relieved by vomiting. The patients were in a state of universal 
uneasiness, which would have been truly alarming, had we not 
known its tendency; but this state is well understood, even by 
the servants of a Fever Hospital, who soon come to know, by 
these symptoms, that the patient is near Hhe cool.^ This state 
sometimes lasted for the greater part of a day, during which time, 
one of our experienced nurses, who was fond of figurative lan- 
guage, would generally remark, that Hhe cool was hovering round^ 
the patient."^ Whatever was the form of this ^^ salutary eff'ort,^^ 
it was generally completed by a warm perspiration flowing from 

» Trans, of Phys. of Ireland, vol. i. p. 299. 
2 Dub. Hosp. Rep., vol. ii. p. 17. 



DURATION AND MARCH.—CRISES. 227 

the whole surface of the body. Dr. Cheyne enumerates many 
other occasional modes of crisis, which seem to have consisted 
merely in the occurrence of some more or less striking symptom, 
such as diarrhoea, or expectoration, or a simple chill, just preced- 
ing, or at the commencement of, convalescence; and concludes 
the subject by saying, that in many instances, he could not dis- 
cover any critical effort, the disease gradually terminating, as 
some of the older authors have remarked, by " insensible resolu- 
tion.^^ 

Dr. Stewart, of Glasgow, in reference to this subject, says; — 
"All that I insist upon is the frequent, I may say the common, 
occurrence of a perceptible crisis, or what is vulgarly termed a 
turn in typhus. I think I may appeal to the experience of every 
physician, and more especially of every resident clerk in a fever 
hospital, — for they have more constant opportunities of observa- 
tion, — whether they have not often been struck at seeing, during 
their morning visit, the glassy eye, the haggard features, the low, 
muttering delirium, the stupor approaching to coma, the tremor, 
the subsultus, the carphology, the rapid, thready, tremulous, and 
intermittent pulse, of the previous evening; the formidable array 
of symptoms, in short, which seemed to indicate a speedy and 
fatal termination, exchanged for the clear eye, the intelligent 
countenance, the steady hand, the comparatively slow and firm 
pulse, and the returning appetite of approaching convalescence. 
To such cases as these, we might almost apply the scripture 
phrase, ^At such an hour, the fever left him;' and if the crisis is 
not very frequently so marked, we can, in the great majority of 
eases, point with precision at least to the day on which amend- 
ment began to take place. "^ 

The following is Hildenbrand's description of the stage of the 
disease, immediately succeeding to the crisis. It constitutes his 
seventh period. " The first striking symptom that disappears is 
the delirium. The patient awakes, as it were, from a dream, or a 
fit of intoxication ; his head becomes free, and in some instances, 
he has an instantaneous and perfect recovery of his former know- 
ledge. The memory, however, is still peculiarly affected; so 
much so, that the patient has great difl&culty in recalling to mind 
the circumstances that passed before and during his illness. The 

' Edinburgh Med. and Surg. Journal, Oct. 1840. 



^28 TYPHUS FEVER. 

mind also experiences a considerable change, and the indifference 
which was previously observed in the patient now begins to dis- 
appear. The eye becomes more attentive and expressive; sur- 
rounding objects begin to excite an interest, and the patient takes 
more notice of what is going on; the insensibility of the soul is 
dissipated; and the feelings of gratitude, of love, and of friend- 
ship, as well as of every other sentiment of the soul, are gradu- 
ally awakened and displayed in the most exalted degree. 

"iAliile the nervous system resumes its ordinary functions, and 
the locomotive powers become more energetic, the functions of 
the circulation are re-established, and the pulse becomes calm, 
regular, and open, though it is frequently weaker than in the pre- 
ceding stages of the disease; the heat and perspiration of the 
body become mild and uniform; the thirst completely disappears, 
and the drinks which formerly afforded so much comfort to the 
patient now become disgusting."^ Hildenbrand also notices par- 
ticularly the extreme muscular debility which accompanies this 
stage of the disease. 

Sec. m. — SequelcE. Typhus fever is not often followed by 
chronic affections, which can be referred to the previous disease. 
Dr. Cheyne, and some others, speak of an occasional case of 
phthisis, chronic rheumatism, hydrothorax, and so on, as amongst 
the sequelce of typhus fever ; but the general testimony of the Irish 
physicians is against the frequency of such results. This is very 
striking in the Reports from many districts of the country, which 
are published in Barker and Cheyne 's account of the epidemic of 
1817, 1818, and 1819. They almost all agree in sapng, that the 
disease rarely left any dreg behind it. Sir Gilbert Blane noticed 
that ships arriving in the West Indies, from England, with their 
men suffering from typhus, were more liable than others to exten- 
sive visitations of dysentery.^ 

Sec. rV. — Relapses. The statements of British writers, in re- 
gard to the frequency of relapses, are quite contradictory. In 
most of the communications contained in Barker and Cheyne's 
history of the epidemic of 1817, 1818, and 1819, relapses are 
stated to have been of very frequent occurrence. At Cork, the 

' Gross's Hildenbrand, p. 52. 2 Obs. Dis. of Seamen, p. 356. 



DURATION AND MARCH.— RELAPSES. 229 

number of persons who relapsed was estimated at two thousand. 
At Waterford, the relapses amounted to one-fifth or one-sixth of 
the whole number of the sick.^ This tendency to relapse was 
most striking during the latter period of the epidemic. It would 
seem to exist during certain periods, and to be absent during 
others. Dr. Stewart says, that however long may be the period 
of excitement, however long the adynamic stage, however tedious 
the period of convalescence, he has never, amongst thousands of 
cases, seen a single case of relapse, in the proper sense of the 
term, after the symptoms had begun to decline.^ Dr. Edward 
Percival says, that relapses were extremely rare at the Hardwicke 
Fever Hospital; while Dr. Pickels speaks of them as common, 
though mild, at Cork. Dr. Alfred Hudson, in his elaborate In- 
quiry into the sources and mode of action of the Poison of Fever, 
informs us, that in five hundred cases of fever admitted into the 
Navan Hospital in 1840, only two instances of true relapse oc- 
curred, -^ 

• Barker and Cheyne's Account, etc., vol. i. p. 439. 

* Edinburgh Med. and Surg. Journal, Oct. 1S40. 
3 Dunglison's Medical Library. 



230 



CHAPTEK YH. 

MOBTALITT AND PEOGNOSIS. 

The at-erage nMKtafilLy^ of typhus fever, deduced : :: _ 
coiuBderable, nin':575. !:'^r "iit of most other en s oi a 
grare character. :i rs r r^eatly, in difeen: -is, and 
locafifies. Before : t :_ estimate the e- n of our 

i::^:::5:i, in indrr: :n : 5t5 I ":! T^dearor t: : ::r. as 

:iri: " :i5 e^sr niate:::^ "":.- /-.:"" '-:: "'? he done. :.:z ^t..t:31 
r--^ •-' ::;. "i:^ ii^T^^T. : : :"::e of its Tan:^:::::5, 



irker, and Chejne, in ^eir-adiL 
nic of 1817, 1818, and 181 

""-^bis ferer, in that cc r*?- ; r- 

ir^ mentioned ye:: le 

^. 1 t: lofonlyr-: : Jialf 



its 
en 



ed 

.... :ae 

ear 

ut 

rse 

ed 

- " : Jic 

:.c: in 

tber of 



MORTALITY AND PROGNOSIS. 231 

one thousand seven hundred and seventy-five; and the deaths, 
during this period, were one thousand nine hundred and seventy- 
one; making the rate of mortality one in twenty-two, nearly.^ 
The highest rate, for any single quarter, was one in fifteen; the 
lowest, for any single quarter, was one in thirty-two. The ave- 
rage mortality, during the same epidemic, in the South Fever 
Asylum at Cork, was one in twenty-five. 

The influence of age, sex, season, and the condition, and con- 
stitution of the patient, upon the danger of the disease, and upon 
our consequent prognosis, constitutes an interesting and important 
subject of inquiry. 

Typhus, like typhoid fever, is less severe and fatal, in early, 
than in middle life. Dr. Percival says, that amongst the children, 
who were timely removed from the crowded apartments of the 
Bedford Asylum, to the cool and ventilated wards of the hospital, 
and who were properly treated, the fever seldom continued longer 
than seven days in any case, and hardly ever proved fatal. ^ Dr. 
Baker observes, that very few children became the victims of the 
epidemic, in the years 1817, and 1818. Amongst the numerous 
cases of children, which came under his care, he recollects but 
one which terminated fatally ; and in that instance, death was 
occasioned by the supervention of another disease.^ Dr. John 
Cheyne says of the fever of 1818, at the Hardwicke Hospital, that 
persons under twenty-five years of age had the disease mildly. 
This influence of age upon the mortality of typhus fever is placed 
in a very clear and striking light by the statistical researches of 
Dr. Mateer. I copy the following table from a paper of his, in 
the tenth volume of the Dublin Journal of Medical Science, ex- 
hibiting the effects of age upon the mortality of the disease, at 
the Belfast Fever Hospital, from September, 1817, to May, 1835. 

Age. No. of Cases. Deaths. Mortality. 

From 1 to 5 years . 301 . 12 . 1 in 25/^^ , , .,, , .^,, ,. , 

u K * lA u n^n io 1 • Pve n Admitted, 5214; died, 

5 to 10 . 979 . 13 . 1 m 75,-V ( 151 ; being a mortal- 

" 10 to 15 " . 1709 . 36 . 1 in 47^1- fity of nearly 3 per ct., 

" 15 to 20 " . 2225 . 90 . 1 in 24fy or 1 in 34 84-151. 



979 


. 13 


1709 


36 


2225 


90 


1384 


. 74 


1033 


. 81 


677 


70 


553 


76 



From 20 to 25 " . 1384 . 74 . 1 in 24f|"^ Admitted, 3747; died, 

" 25 to 30 " . 1033 . 81 . 1 in 12f| ! 301 ; being a mortal. 

" 30 to 35 " . 677 . 70 . 1 in 9^ ^Vactio^nt'o 



70 
21 



cent, and 
fraction, or 1 in 12 



35 to 40 " . 553 . 76 . 1 in 7fy i35-30i 

Trans, of Phys. of Ireland, vol. iii. p. 456. 2 Ibid., vol. ii. p. 572. 

Ibid., vol, i. p. 288. 



232 TYPHUS FEVER. 



Age. No, of Cases. Deaths. Mortality 

418 . 82 . 1 in 5A" 

«/^« r>r. 1 • c 1 i -aamiuea, iu4i5; died 

302 . 60 . 1 m Sgo I 2I6; being a mortal 

188 . 45 . 1 in 4:^\ fity of nearly 21 pe 

135 . 29 . 1 in 41# J or 1 in 4 179-216 



From 40 to 45 years . 418 . 82 . 1 in 5/,-l Admitted, 1043; died, 



45 to 50 
50 to 55 
55 to 60 



From 60 to 65 
" 65 to 70 
*' 70 to 75 
" 75 to 80 



86 . 31 . 1 in 2fn , , .,, , ,., ,. , 

OA io 1 ^r, Q I ^t^mitted, 171; died, 

cJO . 14 . 1 m tJ 1 60; being a mortality 

25 . 11 . 1 in 22^5 I of 35 15-171 per cent., 

24 . 6 . 1 in 4" J or 1 in 3 nearly. 



Results very similar to the above are shown by an examination 
of the cases received into the Royal Infirmary of Dundee, in 
1836, and 1837. 

It has been very generally observed, amongst the hospital pa- 
tients in Ireland and Scotland, that the rate of mortality is much 
influenced by the period of the disease at which the patient is 
received ; it being much less in those cases that are received in 
the early, than in those that are received in the late stages of the 
fever. This may depend in part upon the circumstance that the 
severity of these cases, sent late to the hospital, would be likely 
to be greater, than that of the general average. This influence 
is very well shown by the following calculation, made by Dr. 
Mateer, and founded upon a grand total of 9,588 patients, treated 
in the Belfast Fever Hospital, during a series of seventeen conse- 
cutive years. 

Day when 
admitted. 

No of 

cases. 
No. deaths.' 13 
Ratio of ) 
mortality | 

fra'ct'ion'al' } 2 3 4 4 4 6 11 10 10 6 10 4 20 

Nos. omit- 
ted. J 

It has been observed, as a general rule, in Ireland, that the 
mortality is considerably greater amongst men, than it is amongst 
women. During certain periods, and in given localities, this 
difierence is very obvious. Thus, at the Cork Street Fever Hos- 
pital, Dublin, in 1817, and 1818, the rate of mortality amongst 
the males was one in sixteen ; while amongst the females, it was 
only one in twenty.^ During the same epidemic, however, at 
Cork, the mortality in the South Fever Asylum, was, amongst 
males, one in twenty-eight and a half, and amongst females, one 

1 Trans, of Phys. of Ireland, vol. ii. p. 568. 



2d 


3d 


4th 


5th 


6th 


7th 


Sth 9th 


10th 


11th 


12th 


1.3th 


14th 


Total 


544 


lOSl 


1669 


1106 


927 


594 


1067 302 


539 


1S7 


247 


167 


750 


95S3 


13 


41 


82 


52 


39 


40 


112 30 


57 


13 


25 


7 


150 


664 



PROGNOSIS.— CONDITION. 233 

in twenty-three.^ During a period of eighteen consecutive years, 
from 1818, to 1835, at the Belfast Fever Hospital, the ratio of 
deaths was, for females, one in fourteen, nearly ; and for males, 
one in seventeen.^ The rate of mortality in the Royal Infirmary 
of Dundee, omitting fractions, in 1836, and 1837, Avas for females, 
one in eighteen ; and for males, one in eleven. It ought, how- 
ever, to be remembered, in partial explanation of this difference, 
that, in many places, the average age of the female is less than 
that of the male patients. Barker and Cheyne say, — "We be- 
lieve that at all times fever, particularly when it assumes a severe 
form, is more fatal to men than to women. "^ 

Although the poor are very much more subject to typhus fever, 
than the rich, and those who are well provided with the material 
comforts and luxuries of life ; it is a singular fact, that the disease, 
when it does occur in the latter class, is more severe and danger- 
ous, than when it occurs in the former. The testimony of the 
Irish physicians to the truth of this circumstance is almost unani- 
mous. Old Rutty, in speaking of the great epidemic of 1740, 
and 1741, says: — " The poor, abandoned to the use of whey, and 
God^s good providence, recovered; while those who had generous 
cordials, and great plenty of sack, perished.^'* Barker and Cheyne 
say: — "In every part of the country, fever was reported to have 
been much more fatal amongst the upper, than the lower classes."^ 
Of eleven physicians, at Cork, who had the disease in 1819, four 
became its victims. At Waterford, at Fermoy, and at Cork, the 
mortality amongst the upper classes ranged from one-third to 
one-fourth of the whole number attacked.* 

Mental anxiety and distress seem to predispose to a grave form 
of the disease. The Irish writers have generally observed, that 
fathers of families, and others, whose character and circumstances 
in life were such as to occasion great depression of spirits, and 
apprehension for the future, were more subject to severe and dan- 
gerous attacks, than those of a different temperament, and in dif- 
ferent situations. Dr. Bracken, of Waterford, says, — "In the 
winter and spring of 1806-7, the attention of the writer was 
forcibly directed to the fatal effect of fever on the fathers of fami- 
lies. Several families in fever w^ere admitted during that period 

' Trans, of Phys. of Ireland, vol. iii. p. 230. 

2 Dublin Jour, of Med. Science, vol. x. p. 40. 

3 Account, etc., vol. i. p. 90. * Ibid., vol. i. p. 95. 6 Ibid., p. 435, 



234 TYPHUS FEVER. 

into the Royal Infirmary of Edinburgh, of which the heads, almost 
without exception, became victims, while the rest escaped. Similar 
coincidences have since that time been repeatedly observed by 
him. Scarcely any medical person needs to be informed that the 
age, habits, probably bad, or diseases derived from them, together 
with the greater mental anxiety and solicitude, naturally belong- 
ing to persons in this relative situation in life, must materially 
enter into the prognosis in all cases, and frequently have the 
worst effects on the termination of the disease."^ Dr. Edward 
Percival remarks, that "fevers which had been preceded by great 
bodily fatigue, and mental anxiety, were uniformly hazardous." 
Dr. Pickels says: — "The disease was very fatal amongst the old, 
and those who were debilitated by previous diseases, especially 
asthma. Of six or seven blacks who had the fever in Cork, all 
died but one." Dr. Arrott, of Dundee, thinks, that of all circum- 
stances increasing the danger and mortality of typhus, the pre- 
vious habitual use of intoxicating drinks is the most powerful. 

Barker and Cheyne say, — "It is a general remark, that epi- 
demic diseases are most fatal on their invasion; and in conformity 
with experience, we find that the late epidemic fever, — that of 
1817, 1818, and 1819, was most mortal at its commencement. 
This is proved by reference to various documents. Thus it ap- 
pears, from a tabular view of the admissions to the fever hospital 
in Cork street, that the mortality decreased, from 62 in 1000, to 
31 in 1000. "2 A similar difference was observed in the epidemic 
of 1800, and 1801. 

Our prognosis, in individual cases, must depend upon a careful 
appreciation of all the foregoing circumstances, and especially 
upon the degree of severity of a certain number of the symptoms. 
Great prostration of strength, at an early period of the disease ; 
profound coma ; and dark purple, or livid, petechice are amongst 
the most unfavorable symptoms. Dr. Gerhard says, that in the 
Philadelphia epidemic, when the stupor was extreme, so as almost 
to amount to coma, the prognosis was nearly always fatal. Dr. 
Edward Percival says: — "The worst symptoms of fever are per- 
vigilium, tympany, singultus, and coma; the most favorable in 
all cases are sleep, a moist tongue, and solvent bowels; a defi- 
ciency of urine is also an unfavorable sign, and its suppression, 

' Barker and Cheyne's Account, etc., vol. i. p. 198. 2 Ibid., vol. i. p. 88. 



PROGNOSIS —ERUPTION. 235 

very commonly a fatal one. When the patient lies at ease on his 
side, and especially if he is observed to relieve himself by spon- 
taneous changes of position, after the fever is much advanced, the 
augury is favorable ; on the contrary, when he continues extended 
and supine, lethargic and muttering, the prognostic is adverse."^ 
Dr. Bateman speaks thus of the tongue: — "The most important 
indications, afforded by the appearance of the tongue, are perhaps 
to be deduced from its changes; that is, from its tendency to 
return to the natural state, whatever the character, which it usu- 
ally maintains throughout, may be. If the clammy tongue becomes 
cleaner, the parched one begins to lose its shining appearance, 
and to exhibit its papilla? surrounded w^ith moisture, or the crust 
of the coated one to soften and loosen, we may generally antici- 
pate a favorable change in the other symptoms, if it have not at 
the same time occurred. Perhaps we may with equal confidence 
prognosticate favorably of the issue of a fever, in which the tongue 
retains much of its natural appearance in the midst of many un- 
toward symptoms ; a circumstance which not very unfrequently 
occurs. The same observation, I believe, is applicable to the 
pulse ; and when both these favorable symptoms concur, that is, 
when the tongue is moister and cleaner, and the pulse less fre- 
quent and softer, than the severity of other symptoms would lead 
us to expect, we commonly see the patient recover, though the 
general indications of danger may be extremely great. "^ "It is 
a consoling symptom," says Hildenbrand, "when the tongue, 
which was before dry and parched, becomes in the least moist 
and supple."^ 

Amongst the circumstances to be considered, in the prognosis 
of individual cases, are the amount, and the character, of the 
eruption; the danger of the disease being somewhat in propor- 
tion to the abundance, and the dark color, of the spots. Dr. 
Henderson found the mortality amongst those with an abundant 
eruption to be one in five ; while amongst those with a scanty 
eruption, it was one in eight and a half, nearly. Of Dr. Stewart's 
one hundred and thirty-nine cases, the eruption was universally 
copious in ninety-six, and the rate of mortality was one in five ; 
it was partially copious in thirty-two, and the rate of mortality 
was one in six and four-tenths; it was scanty in eleven, amongst 

1 Trans, of Phys. of Ireland, vol. i. p. 296. 

2 Succinct Account, etc., p. 43. 3 Gross's Hildenbrand, p. 107. 



236 TYPHUS rzvzu. 

idiom there was only one death. Of nirj-nine cases, wherein the 
eniption was lio^t-colored, tiie deaths were one in twelve, nearly ; 
while of eig^ity cases, wherein it was daik-colored, the deadis 
were one in fonr nearly.^ 

Dr. Henderson fonnd, at the Royal Infinnaij of Edinburgh, in 
1838, and 1839, that subsuUus tendimtm^ to any considerable 
extent, was almost always followed by death.^ 

Dr. Grares, in a paper published in the Dublin Journal for 
July, 1838, speaks <rf contraction of the pupil, as a rery unfeTor- 
able sign in typhus. He says : — **In fever with cerebral disease, 
one of the most alarming symptoms is marked contraction of the 
pupil, and were I called to a case in which ereiy other symptom 
was farorable, but great contraction of the pupil was present, I 
would say, that it was a case of extreme danger. A tendency to 
eren moderate contraction of the pupil is a rery dangerous symp^ 
tom in typhus; but a pupil extremely and permanently contracted, 
or as it has been called, ^ pinhole ptqnly is, or used to be a fatal 
sign." 

Heat of the skin, according to the observations of Dr. Ciiejne, 
would seem to be rather a favorable indication than otherwise. 
He found, that amongst two hundred and fifty patients, who were 
admitted to the Hardwicke Fever Hospital, in the spring and 
summer of 1817, and in whom the temperature of the skin w; 
ascertained on the day of admission, the rate of mortality was 
larger in tbose where the temperature was low, than in those 
where it was high. Amongst eighty-three of these patients, in 
whom the temperature ranged from 98 deg. to 100 deg. Fah,, 
inclusive, there were seven deaths, or one in twelve, nearly ; 
amongst one hundred and twenty-seven, in whom the temperature 
ranged from 101 deg. to 104 d^. Fah., inclusive, there were 
five deaths, or one in twenty-five ; and amongst forty, in whom 
the temperature ranged from 105 d^. to 109 deg. Fah., indusiTey 
there was only a sin^e death. " It was not uncommon," says 
Dr. Cheyne, *'to find the thermometer gradually rising firom 98 
or 99 d^. to 102 or 103 deg., or even higher, while the severity 
of the disease was abating; and, on the other hand, we fi^uently 
observed the temperature declining, while the patient was getting 
worse; thus the patient was often in great danger when the tem-^ 



> Efin. Med. and Smg. Joum^ Or*. IS^. 

* Eain. Me^l a^i Sing. JamnL, toL lii. 7 



PROGNOSIS.— HEAT OF SKIN. 237 

perature of the body did not exceed 98 deg. In some instances, 
for a day or two before death, the mercury did not rise above 96 
or 95 deg. Indeed, in severe cases, after the temperature fell to 
par, or below it, and that without any critical effort, we con- 
sidered its rising again as a favorable change. In examining the 
disordered state of the vital functions, he adds, during the summer 
of 1817, with a view to the prognostics of continued fever, we 
derived more information from the state of the breathing, than 
from the pulse, and more from the pulse, than from the temperature 
of the body."^ 

* Dub. Hosp. Reports, vol. ii. p. 13, et seq. 



238 




CHAPTER vm 

DIAGNOSIS, 

: oBHcInde tMs Esray oa Fevers, wilioTit lalriTig notice of lie ybtt great 

is between the putrid moRgnani and the ahm nervaua fecer : the want 

I am ftilLy peisnaded, hath been oftai fHodoctiTe of no small 

as ttey resemble one aaodier in some respects, diough -v-erv essea- 
tMLj ^ifeo^ in others. Jo 3:5- HrxH^ja:, 

JiL IS plaiEL. felt Ifeeie are, at least, r^o species of condniied fever, both, in Eorope 
arui tfti^ cQUiEDtiy ; and. finrther researciies may Terr possibly 3ho"w more. 

Jajcss Jacksos". 

Ty7^t:s feTer may be ci»i£Miiided with Taiioas ottier diseases ; 
~ : remittent, ferer ; wiili siHne cere- 

: .1 : ~ ;._::-. pnexunoiiia. The most important 

r: l:. li — z'--:. .1 : : :iiiection with its diagnosis^ is that which 

pAoid Jeeer. It may be remembered, 
M :: __ ::-._:.- _^ -jion the general diagno^ erf* &e latter 
i i T i 7 I alluded to this subject, and expressed the Cfpinaon, that 
T — izi : -. : - > consdlated, miUaOy^ SssbmSar ftotn ; with 
Lie :„ _ir rrziark, that this qnesfiflii coold be bes* considered, 
after &e natnral hi^oiy of both £seases had been given. We are 
- — 'Tparedto enter i^on this paiticnlar matter, and to esta- 
c_i_. li ^ as tihds can be done^ Ae differential diagnosis of the 
two feTers. There '^^ howeTer, one preliminary remark, which 
': T :^ :: .: r beie; and that is, that eren if we should come 
: - 15". : .1 . as a qne^lion (rf^stnct scientific and philosophi- 
:>gy, that these two affecticms are essentially and fiinda- 
Z^e; l^iat ^lej are fimis, niere:(y, of one indiTidnal 
'mM Ml Ae hardly lag hHporbrnt, that we skemld be 
hdmnm Aem^ asj&rmsy or vmietiesj of^sease. 
' ' mem^ fke weassHy of am aixande Sagmons 
^fAe esmdmsigm, wUdk I have supposed. 
--; :: \--~z:. :: — e choose so to consider them, are still 
*ij mariea; tiiey difiier, in many respects, so constantly 



DIAGNOSIS.— SYMPTOMS. 239 

and so \viclely from each other, that their diagnosis is none the less 
important, than it would be under the other supposition, that they 
are, essentially, dissimilar diseases. After pointing out their 
principal points of resemblance, and of dissemblance, I will en- 
deavor to exhibit, as fully and as faithfully as I can, the present 
state of the question, in regard to their identity, or non-identity, 
by a reference to the opinions and the investigations of those 
observers, who have paid especial attention to this subject, con- 
stituting, as it does, one of the most interesting, and important, 
which is now occupying the attention of medical men. 

Sec. I. — Symptoms. In their mode of access, typhoid and typhus 
fevers, in many instances, very nearly resemble each other. It 
is pretty evident, however, that, as a general rule, the access of 
the disease is more gradual in the former than it is in the latter : 
typhoid fever creeps on treacherously and obscurely more fre- 
quently than typhus does; and the latter makes its onset suddenly, 
and without any lingering premonitions, more frequently than the 
former does. The seizure of the typhoid fever, in grave cases, is 
much more frequently accompanied with abdominal pain, and 
diarrhoea, than is that of typhus. 

The chief difference between the two diseases, in regard to the 
strictly febrile symptoms, consists in the more pungent and burn- 
ing heat of the surface, which characterizes typhus. Perhaps it 
is more frequently the case, also, in this disease, than in typhoid 
fever, that the temperature of the skin falls manifestly below its 
natural standard, as the febrile excitement declines. I am not 
aware, that there is any thing in the chills, or in the character of 
the pulse, to distinguish the two fevers. Perhaps the latter is 
more uniformly soft and compressible in typhus, than in its related 
disease ; and Dr. Gerhard found it more rarely his-feriens, as it is 
called. 

The odor from the body seems to differ in the two diseases. In 
typhoid fever, when perceived at all, it is usually in the latter 
period of grave cases, and is then of a stale, cadaverous charac- 
ter ; in typhus it is pungent, and ammoniacal, more common and 
more striking. 

The thoracic symptoms are subject to greater variety in typhus, 
than in typhoid fever. In some seasons, they are frequent, and 
well marked ; in others, they are nearly wanting. In the former 



240 TYPHUS FEVER. 

disease, they consist, generally, of dullness on percussion, and 
feebleness of the respiratory murmur over the lower and back parts 
of the chest, and of loose mucous rhonchi; in the latter, of dry, 
sonorous, or sibilant, rhonchi. The cerebral respiration is com- 
mon to both fevers. 

There is a pretty close correspondence in the number, the se- 
verity, and the constancy, of the nervous symptoms, in the two 
diseases. Taking in all grades of severity, they maybe somewhat 
more constant, and prominent, in typhus, than in typhoid fever ; 
the pain in the head may be more intense, and distressing ; the 
stupor maybe more marked; the morbid sensibility of the surface 
seems to be more common, and striking ; and the prostration of 
muscular strength, on the subsidence of the febrile symptoms, is 
more invariable and profound. 

There is one other difference in regard to the existence of which 
I think there can be no reasonable doubt. The nervous symp- 
toms in typhoid fever almost always creep on more stealthily and 
gradually than they do in typhus. This is especially true of the 
dullness and stupor. In the latter disease, this symptom is gene- 
rally more marked and profound at the commencement, than it is 
in the former. 

In the abdominal symptoms of the two diseases, there are nu- 
merous, and important differences. In typhoid fever, where the 
affection is at all severe, there is generally spontaneous diar- 
rhoea, with liquid, yellowish, ochre-colored stools; in typhus, 
there is commonly constipation, and the stools, when procured by 
purgatives, are often dark, slimy, or pitchy, and offensive. He- 
morrhage from the bowels is not unfrequent in the former; it 
hardly ever occurs in the latter disease. Abdominal pains are often 
present in both fevers, but in the former, they almost invariably 
accompany the diarrhoea; in the latter, they are attended by con- 
stipation, and are relieved by cathartics. In the former, they are 
more frequently confined to the right iUac region, accompanied 
by tenderness on deep pressure, and gurgling, than in the latter. 
Tympanitic distention of the abdomen is very common in typhoid 
fever ; it is very rare in typhus. 

The state and changes of the urine have not been ascertained 
with sufficient care, in the two diseases, to enable us to say whe- 
ther they present any differences in this respect. 

The cutaneous eruptions, characteristic respectively of the two 



DIAGNOSIS.— LESIONS. 241 

affections, are very unlike, in many respects. In typhoid fever, 
the spots are pretty uniformly oval, or circular, varying but little 
in size ; often distinctly, though slightly, elevated ; readily dis- 
appearing under pressure ; generally, not very numerous ; con- 
fmed, for the most part, to the skin of the chest, and abdomen ; 
and of a bright rose color. In typhus, they are more irregular in 
their shape, and size; not elevated above the adjacent skin; par- 
tially disappearing under pressure, or not at all ; often abundant, 
and even confluent ; in many cases, occupying the skin of the 
extremities, as well as that of the entire trunk ; and usually of a 
duller, and more dusky, color, than in the former disease. Not un- 
frequently, also, they consist of true petechia?, or cutaneous ecchy- 
moses, which, in fatal cases, persist after death. The average 
period of their appearance seems to be rather earlier in typhus, 
than in typhoid, fever. The dingy color of the skin, the dusky 
suffusion of the face, and the dark injection of the conjunctiva, 
are, to a considerable extent, peculiar to typhus. Such are the 
principal points of likeness, and of unlikeness, in the symptoms 
of these two diseases. I shall now institute a similar comparison 
between their respective lesions. 

Sec. II. — Lemons. There are some differences in the patho- 
logical alterations, which are found in the thoracic organs, in the 
two fevers ; although they are not very striking. The lungs seem 
to be more constantly the seat of some appreciable lesion, in 
typhus, than in typhoid fever. Decided engorgement of their pos- 
terior portions appears to be more frequent, and an unusual accu- 
mulation of frothy mucus in the bronchial tubes. I am not aware, 
that ulcerative destruction of the epiglottis, more or less extensive, 
which occurs in a certain proportion of cases of typhoid fever, is 
ever found in typhus. The state of the heart, in the latter dis- 
ease, has not been particularly enough studied to enable us to 
compare it with that of the same organ, in the former ; and al- 
though there seem to be some differences in the condition of the 
blood, in the two fevers, the same remark may be made of this 
fluid. 

Venous congestion of the brain, with dark fluid blood, appears 
to be more common in typhus, than in typhoid, fever. 

The differences in the abdominal lesions, in the two diseases, 
are very striking, and constant. They are so well marked, and 
16 



242 TYPHUS FEVER. 

SO invariable, that they are easily stated. In typhoid fever, there 
is a peculiar and constant alteration of the elliptical patches of the 
ileum, consisting of various degrees of thickening, changes of 
consistence and color, and especially of ulceration. In typhus, 
these plates are very rarely altered, and when so at all, only to a 
very trifling extent. In typhoid fever, the isolated follicles, both 
of the small and the large intestines, are found to have undergone, 
in many cases, the same changes that occur in the aggregated 
foUicles; in typhus, they are in a healthy condition. In the former 
disease, the mesenteric glands, corresponding to the altered and 
ulcerated follicles, are reddened, softened, and augmented in 
Tolume ; in the latter, they are unchanged in any respect. The 
large intestines are usually more or less distended with flatus, in 
typhoid fever; they are not so, in typhus. The spleen is enlarged, 
and sofl:ened, in a considerable proportion of cases of both dis- 
eases ; but these changes are greater and more frequent in the 
former, than in the latter. Alterations in the thickness, color, 
consistence, and so on, of the mucous membrane of the stomach, 
and intestines, are frequent, but not invariable, in both affections; 
there is nothing of any diagnostic value in their diflerences. 

Sec. m. — Causes. In connection now with the causes of these 
fevers, there are several circumstances, in which they differ very 
considerably from each other. Typhus, although occurring most 
frequently in early life, is not so exclusively confined to this period, 
as typhoid fever is. The former attacks individuals, more than 
forty years old, much oftener, than the latter does. Recency of] 
residence in any given place, although it seems to favor the 
occurrence of typhus, does so much less powerfully, and mani- 
festly, than of typhoid fever. The unknown causes of the latter 
disease, connected with locality, are less circumscribed, geogra- 
phically, than those of the former ; at any rate, they seem to be 
more constantly and uniformly present over more extensive regions 
of the earth. In other words, typhoid fever is widely and con- 
tinually prevalent, in many places where tvphus is very rarely, if 
ever, seen. The sporadic character of the former is more marked 
and evident, than that of the latter. Typhus prevails more fre- 
quently, in an epidemic form, than typhoid fever. The latter dis- 
ease may be, to a certain extent, and under certain circumstances, 
contagious; but it is much less evidently and decidedly so, than 



i 



DIAGNOSIS.— DURATION —EFFECTS OF REMEDIES. 243 

the former. The connection of crowded, filthy, and poorly ven- 
tilated apartments, with the origin and propagation of typhus, is 
more manifest and unequivocal, than with those of typhoid fever. 
This latter point deserves to be much more strongly and em- 
phatically stated than it was as above in my first edition. It 
seems to me to constitute a broad, unequivocal, and most striking 
difference betw^een the two diseases. Typhus fever is very inti- 
mately connected in its etiology with crowding, impure air, filth, 
and poverty ; it is, to a very great extent, dependent upon these 
causes for its primary origin. There is no point in its natural his- 
tory more positively settled than this. Many of the British writers 
allege that the entire removal of these causes would exterminate 
the disease. Now all this is entirely otherwise, so far as typhoid 
fever is concerned. I do not mean to say that crowding, impure 
air, filth, and destitution may not sometimes give rise to typhoid 
fever, and favor its prevalence, although there is very little evi- 
dence, if any, that they ever act in this manner. But I do mean 
to say, that as a general rule, the disease is in no w^ay, and in no 
degree, dependent upon these causes. In a vast majority of in- 
stances, it is entirely impossible to trace any connection between 
them ; nay, more than this, it is entirely manifest that there is no 
such connection. The poison of typhus fever is generated in a 
stagnant and depraved atmosphere, rank wdth the thick corruptions 
of concentrated emanations from the living human body; — the 
poison of typhoid fever, like that of epidemic cholera, and like 
that of scarlatina, comes we know not w^hence ; it is generated 
as readily amidst cleanliness and purity as amidst filth ; and it 
floats as freely in the fresh breezes under the open sky, as in the 
close and stagnant atmospheres of crowded cabins and lanes. 

Sec. IV. — Duration. The average duration of typhus is con- 
siderably less, than that of typhoid fever; and death from the 
former disease occurs, in many cases, earlier, than from the latter. 
The termination of the disease by a more or less w^ell marked 
crisis is also much more common in the former, than in the latter. 

Sec. V. — Effects of Remedies. Finally, it is very evident, I 
think, that these two diseases differ from each other, in the effects 
which are produced upon them by remedies. The immediate 
influence, for instance, of treatment, is much more obvious in 



244 TYPHUS FEVER. 

typhus, than it is in typhoid fever. General or local bleeding, 
■when it is indicated, is more uniformly followed by mitigation, or 
removal, of local pain, especially of that of the head. So, the 
administration of stimulants, and tonics, under circumstances that 
call for them, is more frequently followed by a strong and mani- 
fest impression upon the morbid actions, than is often seen in 
typhoid fever. It is pretty clear, also, that, as a general rule, 
typhus requires a more tonic and supporting treatment, than the 
latter disease. M. Bouillaud may have failed to show, that ty- 
phoid fever is more successfully treated by repeated bleedings, 
general and local, even at periods of the disease somewhat ad- 
vanced, and independent of any special local indication, than by 
any other plan ; but he has at least demonstrated, that this treat- 
ment may be borne with a good degree of impunity. We rarely 
hear of the sudden and often fatal sinkings, and collapses, which 
have so frequently followed a single moderate abstraction of blood, 
in the middle and later stages of typhus. 

Sec. VI. — Historical. If this alleged, and well-defined differ- 
ence between typhoid and typhus fevers really exists ; if these two 
diseases are, radically, and fundamentally, diverse, and unlike 
each other ; and if the diagnosis between them can be generally 
established, it becomes a matter, not only of scientific interest, 
but of great practical moment, for us to inquire how far this dis- 
tinction is recognized, either in form or in fact, by the leading 
and classical British writers, who have long been, and who still 
continue to be, to a very great extent, at any rate, our guides and 
authority, on the subject of continued fever. What do they mean 
by the terms typhus fever, common continued fever, slow nervous 
fever, and so on? Do they describe a single disease, essentially 
identical in its nature, and differing only in its form, under these 
several appellations? If so, what is this disease? Is it the typhus 
fever, or is it the typhoid fever of this book? On the other hand, 
do they describe distinct and separate diseases, under these several 
appellations? If so, what are these diseases? Are they typhoid, 
and typhus fevers, or are they something else? Certainly, I need 
not say how necessary it is to all sound science, and to all suc- 
cessful, or even safe, practice, that we should understand each 
other upon this primary and fundamental point of diagnosis. 
Certainly, I need not say what contradictions and what inex- 



DIAGNOSIS.— HISTORICAL. 245 

iricable confusion must inevitably grow out of the want of this 
understanding. In order to determine, as far as may be, the 
questions above indicated, I will briefly examine the opinions and 
observations of some of those British authors, whose works are 
most generally in the hands of our own practitioners, and whose 
writings have most extensively influenced their doctrines and their 
]nactice. Amongst these, I may mention particularly, John 
Armstrong, Southwood Smith, and Alexander Tweedie. 

In Dr. Armstrong's '^Practical Illustrations,^^ there is a great 
deal of gratuitous generalization, and of loose diagnosis; but he 
nevertheless admits, very distinctly, the existence of two distinct 
forms of fever. One of these he calls typhus fever; and the other, 
common continued fever. He uses the term typhus, he says, not, 
as has often been the case, to designate the combination of malig- 
nant symptoms, which may take place in the last stage of any 
acute disease, but *^to denote a specific disease, that, like the 
epic poem of ancient critics, has a beginning, a middle, and an 
end." The common continued fever of Dr. Armstrong is, I think, 
the typhoid fever of Paris, and of New England. Some of the 
leading and prominent distinctions between the two diseases, 
already so fully pointed out, in the foregoing pages, can hardly 
fail of being recognized in the following extract: — "The disturb- 
ance of the sensorial functions, and the prostration of the moving 
powers, are remarkably characteristic of true typhus. In the 
most frequent forms of the common continued fever, the patient 
has uneasiness in the head, but he has a bright eye, and a coun- 
tenance indicative of no mental depression, or despondency, and 
be lies in a position which displays some command of muscles, 
and can move about the bed, or get up, with a tolerable effort. 
On the contrary, in genuine typhus, the eye always wants anima- 
tion, the countenance has a dull, wearied, depressed, and often 
desponding, expression, and the patient lies in a comparatively 
relaxed position, and moves himself more languidly, almost like 
one worn out by loss of sleep, and from some unusual fatigue. 
Ill the common continued fever, the patient commonly has not 
much inaptitude of mind, often answers questions readily, and in 
a pretty firm voice, without much increased agitation of the 
breathing; whereas, in typhus, the answers are mostly given with 
languid slowness, and reluctance, and much speaking obviously 
disturbs the respiration. In the common continued fever, the 



ty:-ezs rzTER, 



dask^ : -is. and an admistme of it may be best ob- 

aeiTr T : ^ :"3ce- This duskiness of the skin is <Mie 

of Vlz ::::-: £ ::i: . -- : tyj^ns, and seems to aiise from some 
change in die constitoticm of tbe blood, which I haTe almost 
in^andbly seen daiker, Iban in oidinaij feTeis. In the wcnst 
cases, fbe dni^iness increases in the progress of tbe disease, and : 
lessens in Ibose tbat assume a mUd ai^pecL So Teiy charactetislic 
isfbis cutaneous doziness, Ibat I think I could distingnish typbns| 
bj it, at any time, if two patients were presented to me, the cmel 
laboring umler that disease, and tbe ofber nnder tbe 
continned feTer. In typbns, tbe tongue has an eailj tendency] 
to become brown and dry, in tbe commim continued ferer it is] 
always while, and of^ even somewbat mmsA for tbe first wedk;;j 
in t^T^iMs. 'r :!se is Tariable as to force and frequency, but ili 
is srli : — '"-.J- . rsisting to pressure, but in tbe c<»nmfm continued^ 
foTer, it mostly resists finn pressure of tbe finger, from tbe 
stroke i^the beart. Tbe abore remaiks are ceitainly most ^ipi 
priate to tbe first and middle stages of tbe indinaiy instances 
typhus, and of tbe common ccmtinued leTer; fiir, in tbe last 
of both, many c^ l9ie symptoms so approsimate, as to make 
more neady resemble eacb other. "^ Dr. Aimstrong also 
ci the peculiar odor from tbe body in typbus fever, of tbe ap] 
ance : f r itf :^ " ~ . :: - of tbe frequency, and gravity, of pi 
comr-::in:L;. -^_; 

COET L r 

mos: 
mic; r 
remeii t 
fevt: : 



: L .' . .-. — :. gst tbe occa^nal symptoms of the coi 
irTer, be mentions epistaiis, and dianboea; and 
7 Le says, deatb occuis at tbe end c^ lAke second, 
r tiird, wedc, but sometimes later. Now wben it 
: tbe diagnods between this conumm cont 
- - - 5 ~gy and many local inflammations, was 
ished, wben bis bode; was written; tbat 
char: : i beoi but paitiaDy asceitained; 

oflif: :i :. :t5; :' ^rn have been confounded 

it, v^T _ 7 l: _ ± I -V, incoming to tbe 

aion, tbat, with tiiese : .: i ; - disease described by . 

Amsrri-r is tie : izmmii c^zrOTLTieii lever, is identical widi 



IsB Feves, e/te. Bf Join A u a stfa uMg, pu 234»4 



DIAGNOSIS.— HISTORICAL. 247 

typhoid fever of the present day, and that his typhus fever is the 
typhus of the present day. 

Dr. Armstrong thinks, that there is a third form of fever, occa- 
sioned by the crowding together of a great number of persons, in 
fihhy and close apartments, differing from both the preceding 
fevers. His notice of it is too short and imperfect to enable one 
to judge of the correctness of this opinion; but the disease w^hich 
he describes, was, probably, a form of typhus. 

Dr. Southwood Smith denies the existence of more than one 
continued fever. To the several forms and varieties of this single 
fever, depending upon degrees of severity and complications, he 
applies different terms; merely, however, as a matter of con- 
venience. *'The more we investigate the subject," — he says, — 
''the more satisfied we shall become, that continued fever is one 
disease, and only one, however varied or even opposite the aspect 
it may present; but that it differs in intensity, in every different 
case, and that this, and this alone, is the cause of the different 
forms it assumes."^ 

Notwithstanding this opinion of Dr. Smith, an attentive study 
of his book, with our present knowledge upon this subject, will 
lead us, I think, to the conclusion, that the two diseases, which I 
have described, the typhus, and the typhoid, fever, both fell under 
his observation, and both helped to furnish the materials for his 
work; although he failed, as his predecessors and cotemporaries 
had done, to discover, and to distinguish, clearly, the differences 
between them. It must, however, be added, that his histories of 
the several varieties of fever are not sufficiently full, and accurate, 
to enable us, ahvays, to make a satisfactory diagnosis. His 
descriptions are glowing and vivid enough, too much so perhaps, 
but they are not diagnostic; they are not discriminating: they are 
not complete. Like those of almost all English writers upon 
fever, they are not pure ; they are mixed up, and corrupted, with 
a priori and hypothetical explanations, and interpretations, of the 
symptoms. 

His synochus mitior seems to be a mild form of typhus, although 
it is impossible to speak with any confidence, from his descrip- 
tion. The same remarks may be made, excepting as to the seve- 
rity of the disease, of his synochus gravior, with sub-acute, and 
with acute, cerebral affection, and wdth thoracic affection. His 

'■ A Treatise on Fever. By Southwood Smith, M.D., Boston, 1831 j p. 41. 



248 TYPHUS FETER. 

synochus gravior^ with abdominal affection, corresponds more 
nearly to typhoid fever. Some of the cases, included in this sub- 
division, certainly belong to the latter disease. His several va- 
rieties of typhus^ corresponding to those of synochus, and except- 
ing that with abdominal affection, are, pretty evidently, for the 
most part, made up of cases of true typhus, ffis typkas mUior, 
with abdominal affection, looks more like typhoid fever. 

Now, taking the evidence derived from the symptomatology 
alone, in these descriptions by Dr. Smith of his several forms, 
and modifications, of continued fever, ane thing, at least, we may 
look upon as settled. If, on account of the incompleteness and 
vagueness of Dr. Smith's general and particular histories of the 
disease, we are not justified in deciding positively, that the two 
distinct fevers, as I have described them, were both present in 
the London Fever Hospital, we may with entire confidence assert, 
that these histories contain no evidence, whatever, that soch was 
not the case. So far as the evidence derived firom this source 
goes at all to settle the question, aided and interpreted, as it now 
is, by our present knowiedsre, it goes to show, that both typhoid, 
and typhus, fever, but principally the latter, constituted the dis- 
ease which Dr. Smith describes ; and this conclusion we shall 
find singularly corroborated by an examination of his cases, illus- 
trative of the pathology of the disease. 

His general description of the lesions found after death is too 
loose and imperfect, to be much relied upon. He speaks of the 
diisky- color of the skin, the large, purple, petechiae, and the dark 
color of the muscles, and the internal viscera. The brain is de- 
scribed, as usually morbid ; either increased vascularity of its 
membranes, and substance, or serous effusion, constituting the 
most common alteration. We may, however, well feel the ne- 
cessity of caution and skepticism, when we find it stated, as it is, 
that " the pituitary gland is very constantly softened, and often 
in a state of suppuration." The mucous membrane of the bron- 
chial tubes was very generally thickened, and of a dark red cdor. 
The lower portion of the small intestine is said to have been found, 
in many cases, more or less extensively diseased ; its mucous mem- 
brane sometimes only reddened, and vascular, and at others the 
seat of ulcerations. These ulcerations, with alterations in the 
mesenteric glands, seem to have been identical with the entero- 
mesenteric lesion, which I have describedj as characteristic of 



DIAGNOSIS.— HISTORICAL. 249 

typhoid fever. In a large number of cases, on the other hand, 
the intestine is said to have been free from disease. Now, the 
point to which I wish more particularly to refer, illustrative of the 
question before us, is this ; the average age of the patients, con- 
stituting the two classes of cases'; those which did, and those which 
did not exhibit, after death, the peculiar lesion of the elliptical 
plates, found in typhoid fever. I find, for instance, that there are 
thirty-five cases, reported, of fever with prominent cerebral affec- 
tion, and with absence of intestinal ulceration ; and that the ave- 
rage age of these cases is thirty-four years. Of these patients, there 
were thirteen, who were over thirty-five years of age ; ten of them 
were as high as fifty, and the oldest was sixty-five. There are 
eight cases, reported, of fever with prominent thoracic affection, 
and with no ulceration of the intestine. The average age of these 
cases is somewhat more than thirty-six years. There are three 
cases, reported, of fever with prominent abdominal symptoms; 
but without ulceration of the ileum; and the average age of these 
is forty-five years. There are eight cases, reported, of mixed dis- 
ease, without ulceration, the average age of which is twenty-two 
years and a half. The average age of these fifty -four cases is about 
thirty-three years. I find, furthermore, forty cases, reported, 
wherein the intestinal ulcerations, characteristic of typhoid fever 
were present; and the average age of these cases is twenty-two 
years and a third. Only four of them were over thirty-five, and 
the oldest was fifty years of age. The bearing of this result 
upon the question of the existence of typhus, and typhoid, fevers 
amongst Dr. Smith's cases, and of the diagnosis between them, 
is too obvious to require any further remark.^ 

Dr. Alexander Tweedie's Clinical Illustrations of Fever were 
published in 1830. This work is more fragmentary in its cha- 
racter, and less systematic, than the treatise of Dr. Smith; but it 
bears many marks of sound judgment, and careful observation. 
Dr. Tweedie seems to be very strongly impressed with the fact, 
that different and diverse fevers prevail in London; but he has 
failed to point out, with any degree of accuracy, or completeness, 

' Dr. Reid's one hundred fatal cases have already been spoken of. There were 
only six of them which presented the lesion of typhoid fever; the average age of 
these six cases was twenty-five years ; the average age of the one hundred cases 
was thirty-six years and a third ; seventy-seven were over thirty, and forty-two wera 
over forty. — Edin. Med. Journ., Aug. 1842. 



250 TYPHUS FEVER. 

their distinguishing characteristics. His work, like that of Dr. 
Smith, is thus rendered almost valueless, by the fatal and funda- 
mental defect of a want of all clear, and well-defined diagnosis. 
This is true in relation not only to the separate kinds of fever, 
but also to other and widely different diseases. Thus, under the 
head of continued fever, we find many cases, which are, mani- 
festlv, not fevers of any kind. These are instances of peritonitis, 
pneumonia, phthisis, and so on. Under these circumstances, and 
from such imperfect data, it would be worse than idle to attempt 
to settle the important question of the kind and character of the 
fever, or the fevers, which are described by Dr. Tweedie. I wish 
merely to remark, that an examination of his cases, in reference 
to their average age, furnishes the same singular corroboration of 
the correctness of the opinion, which I have given, in regard to 
the existence amongst them of both typhoid, and typhus, fever, 
as has already been deduced from a similar examination of those 
of Dr. Smith. For instance, of fifteen cases, which, as far as I 
can judge, seem to have been cases of fever, and in which there 
was no intestinal ulceration, the average age was about forty 
years; while of sixteen other cases, in which the lesion, charac- 
teristic of typhoid fever, seems to have been present, the average 
age was less than twenty-six years. 

By some of the older British physicians, however, amongst 
whom may be mentioned, especially, the incomparable Huxham, 
the difference between these two forms of fever was distinctly no- 
ticed. I have already given an extract from this writer's Essay 
on the Difference between a Slow JVervous and a Putrid Malignant 
Fever ; in which, considering the time when it was written, and 
the comparatively imperfect study of diagnosis, which was then 
common, the peculiar features of the two diseases are very well 
delineated. 

In a letter from Dr. Darwin to Dr. Lettsom, dated, Derby, Oc- 
tober 8th, 1787, the following passage occurs : *' If your Society 
proposes questions, I should wish to offer for one, 'Whether the 
nervous fever of Huxham (or fever with debility, without petechias 
or sore throat, or flushed countenance, or pungent heat), be the 
same as the petechial fever, or jail fever ?' The former of these, 
viz., the nervous fever of Huxham, prevails much over all the 
country at this time."^ 

* Life and Correspondence of Dr. Lettsom, vol. iii. p. 118. 



DIAGNOSIS.— HISTORICAL. 251 

Dr. Vaugban, also, of Leicester, in a letter to Dr. Lettsom, 
dated July 27th, 178^, in reference to the same subject, observes: 
— " There is surely a peculiarity in the species of fever you had 
the goodness to send me an account of, protracting itself to such 
a length as thirty-five or forty days: it certainly agrees very much 
with Huxham's Febris Nervosa, which, notwithstanding Br. Cul- 
len, is a very different disease to the Febris Carcerum, in its attack, 
progress, termination, and cure.'^^^ 

Cotemporary with these authorities, and inferior, certainly, to 
none, is that of Sir John Pringle, who very distinctly recognizes 
the difference between jail fever, or typhus, and the low, nervous, 
miliary, or typhoid fever. " In the description," he says, "I have 
endeavored to distinguish them" — i. e. malignant or pestilential 
fevers, — " from all others, as far as I could do it in distempers whose 
symptoms are so much alike. The nervous fevers are frequently 
accompanied with miliary eruptions, wdiich have no resemblance 
to the petechial; nor have I ever happened to see miliary eruptions 
in this malignant kind."^ In reply to some strictures of De Haen, 
he says, still more explicitly, — "I have never considered the jail 
or hospital fever, and the miliary fever," — meaning the low, nerv- 
ous, or typhoid, — " as similar ; and, indeed, I may venture to 
say, that, as the symptoms of the two are so much unlike, they 
ought to be treated as different in specie; and, consequently, that 
neither the theory nor the practice in the one ought to be regulated 
by analogy from the other."^ Again, he says, — *'I have, there- 
fore, all along considered the jail, or hospital fever, (in regard to 
others, that commonly occur in these parts,) as a fever sui generis, 
at least as different from either the scarlet, the miliary, or any 
other eruptive fevers, w'hich are known."'* 

The strictures alluded to above, by De Haen, had reference, 
particularly, to the treatment of fever, by Huxham and Pringle. 
De Haen charged these great British observers with bad practice, 
with a too stimulating and incendiary method in the management 
of fever. Pringle, in his reply to De Haen, says, expressly, that 
the fever treated by the latter at Vienna was of a different kind 
from that treated by himself; and in a note to this reply, he makes 

1 Life and Correspondence of Dr. Lettsom, vol. iii. p. 161. 

2 Observations on the Diseases of the Army. By Sir John Pringle. Philad. ed., 
p. 298. 

3 Ibid., p. 384. 4 Ibid., p. 385. 



252 TYPHUS FEVER. 

the following very interesting remarks in regard to the dissimi- 
larity of the cutaneous eruption in the two diseases. "After 
publishing what is above, relating to the distinction, which I con- 
ceived was to be made between De Haen's petechice and mine, I 
was confirmed in my opinion by Dr. Huck, who, in the year 1763, 
was at Vienna, and was favored with admittance into all the hos- 
pitals there, and in particular had the satisfaction of attending Dr. 
De Haen himself, and seeing, with that celebrated physician, some 
of his patients in that very fever, which he calls petechial. Dr. 
Huck examined those spots in Dr. De Haen's presence, and assured 
me, that they had hardly any resemblance to those which I have 
called petechial, and which he himself had so often seen in the 
hospitals of the army ; but that they were so like flea-bites, that 
he was apt to believe, that one must be often mistaken for the 
other. "^ Let me add, here, that I do not know anything in the 
annals of medical polemics, imbued with a finer temper, or a more 
philosophical spirit, than this reply of Pringle to De Haen. It is 
every way equal, — and there is no higher praise than this, — to 
Louis's defences against the attacks of Broussais and Bouillaud. 
In place, or out of place, I cannot forego the pleasure of gracing 
a page of my book with the following golden words from the reply 
of Pringle. " In fine. Dr. De Haen may be assured, that the re- 
gimen, which I propose, stood at first on no other foundation than 
experience, after my having seen the bad eflfects of a contrary 
method, whether by too large, or too frequent bleedings in the be- 
ginning; or by giving hot things too early, in order to raise the 
pulse, when it began to sink, or to force a crisis before the com- 
mon period of the disease. Some of the medicines are superflu- 
ous, but I am pretty sure, that none of them are hurtful. * * * 
But having once got into a method, which brought about as many 
cures as seemed otherwise consistent with the circumstances of 
my patients, lying in a foul air, amidst a constant noise, and often 
neglected by the nurses, I did not attempt to reduce my practice 
to more simplicity than what is mentioned. Yet, whatever confi- 
dence I may have in the directions, which I have published, I am 
still ready to alter any part of them, upon a fair representation 
from those who have had equal opportunities with myself of seeing 

* Observations on the Diseases of the Army. By Sir John Pringle. Philad. ed., 
p. 390. 



DIAGNOSIS.— HISTORICAL. 253 

and treating this fever. But to oppose either mere theory, or 
analogy from other fevers, where the similarity is so disputable; 
or to oppose some general maxims from Hippocrates or Sydenham 
to the observations, which I have offered, as the result of a long 
and painful experience in a distemper that no physician could 
well know but in such circumstances as mine, is a manner of 
writing, I must say, more fitted for disputations in a school of 
medicine, than for the instruction of a practical physician."^ 

Dr. Macbride, of Dublin, says, that the ^'Putrid Continual 
Fever, before Dr. Langrish's^ time, was confounded with the nerv- 
ous: but though both nervous and inflammatory fevers, towards 
the close, often show that by that time the crasis of the blood is 
destroyed, yet we are not to confound them with this" — the putrid 
continual — " wherein, from the very beginning, there is some pecu- 
liar acrimony, which dissolves the bond of union among the in- 
sensible particles, and allows them to run into combinations oppo- 
site to the mild, smooth, and emollient nature of blood in the 
healthy state. "^ 

Dr. Willan, in speaking of the contagious typhus of London, in 
1799, says, — ^' To this contagious fever alone Dr. Cullen ought 
to have applied the denomination of typhus mitior: he has impro- 
perly comprised under it the slow, or nervous fever, described by 
Huxham and Gilchrist, which may rather be considered as a spe- 
cies of hectic, and is not received by infection. ""^ 

Dr. James Sims, of the county of Tyrone, Ireland, although 
disposed to doubt the existence of the distinctions between the 
slow nervous, and the putrid fever, insisted upon by Huxham, still 
says, — " I would not by this be understood to mean that there is 
no difference in reality between a low nervous fever, as it is called, 
and a putrid malignant one ; I am well aware that there is, but 
am afraid that, in the last stage of the nervous one, as described 
by Dr. Huxham, a change is brought about by his treatment of it 
that he little suspects, which is its degenerating into a truly putrid 

1 Observations on the Diseases of the Army. By Sir John Pringle. Philad. ed., 
p. 395. 

2 ''The Modern Theory and Practice of Physic, by Browne Langrish, M.D., 
Lond. 1735." 

3 A jNIethodical Introduction to the Theory and Practice of Physic. By David 
Macbride, M.D. London, 1772, p. 324. 

* Med. and Phys. Journ., vol. ii. p. 412. 



254 TYPHUS FEVER. 

malignant fever in nothing distinguishable from the other described 
under that appellation."^ 

In Vol. IV. of the Edinburgh Medical Essays and Observations, 
1734, there is an Essay on Nervous Fevers, by Dr. Ebenezer 
Gilchrist, of Dumfries. The disease described by Dr. G. is evi- 
dently typhoid fever. " / take this /ever," — he says, — " to he 
very different in its nature and changes from other fevers.''"' 

In a continuation of the same essay, in Vol. VI., Dr. G. thus 
describes the disease. " The Fever runs out to the twentieth, 
twenty-fifth, thirtieth, and sometimes to the thirty-fifth day. The 
symptoms upon seizure are generally such as are common to all 
fevers, coldness, trembling, and frequent alternations of heat and 
cold, nausea, headache, and vomiting; while at other times it 
draws on more insensibly. * * * From the seventh or eighth 
day, sooner or later, a delirium comes on, which is constant, and 
lasts through the fever, but for most part is not very high ; the 
tongue is black, chapped and parched. The sick are faint, highly 
dispirited, sigh heavily, and, when the fever is vehement, have a 
nervous or intercepted breathing. * * * A symptomatica! loose- 
ness, or deafness, or both, accompany it to the end. "What 
deserves a serious consideration, is the frequent hemorrhages, or 
bloody appearances that happen. I have known them bleed four 
or five pounds by the nose in a few hours : bloody or sanious stools, 
and very fetid, are observed. * * * Seldom do they die soon in 
the disease, though it has been fatal before the fourteenth day." 
* * * "The disease, before it makes its attack, gives sufficient 
warning sometimes. Two or three weeks before they are laid 
down, they are low-spirited, inappetent, loaded, sleep ill, sigh fre- 
quently, groan involuntarily, and feel inexpressible disorder, ac- 
companied with great fear, concern, and dejection, and perhaps, 
slight alienation of mind." The essay is long and tediously 
stupid, Avith a priori reasonings. 

Twenty-five years ago, an interesting paper was published in 
the Edinburgh Medical and Surgical Journal, by Dr. Autenrieth, 
Jr., on the Sporadic Abdominal Typhus of Young People, as the 
disease showed itself in the south of Germany. The difference 
between it and the typhus is distinctly recognized; although, as 
the author remarks, the two diseases had generally been con- 

' Obs. on Epid. Dis., p. 248, 1776. 



DIAGNOSIS.— HISTORICAL. 255 

founded. Dr. Autenrieth, Jr., says expressly, and in so many 
words, that the disease, which constitutes the subject of his essay, 
is essentially distinguished from typhus; by arising independently 
of any contagion; by the particular time of life, in which it spon- 
taneously occurs ; and by the seat of the complaint being in the 
abdomen, rather than the brain. Amongst the symptoms, which 
the author enumerates, and which show very clearly its identity 
with typhoid fever, and its difference from typhus, are watery 
diarrhoea, abdominal pains, tympanites, and epistaxis. Dr. Au- 
tenrieth's sketch of the disease was written from memory, while 
he was residing in Edinburgh, and at the close of his paper, he 
refers to a more exact and comprehensive description of the dis- 
ease, to be expected from the hand of his father. "If," he says 
in conclusion, "by the present attempt, I should be so happy as 
to excite the attention of the British medical profession to the 
knowledge and cure of this disease, I entertain the hope, that in 
a short time the science may be enlarged, and my design com- 
pletely attained." It is not a little remarkable, that the attention 
of British observers should have been especially called to this 
particular subject, — the distinctions betw^een these two forms of 
fever, — fourteen and sixteen years subsequent to the publication 
of Dr. Autenrieth, Jr.'s, paper, by two other young continental 
physicians, — Dr. Lombard, of Geneva, in 1836 ; and Dr. Staberoh, 
of Berlin, in 1838. 

I shall now give a summary of the investigations which have 
been made, and of the opinions which have been advanced, in 
regard to this very important question, during the last few years. 

Dr. E. Hale, Jr., of Boston, in a paper on the typhoid fever of 
New England, published in the Medical Magazine for December, 
1833, speaks verydecidedlyof the want of correspondence between 
the descriptions of typhus, given by Dr. Armstrong and Dr. South- 
wood Smith, and the phenomena, presented by the common fever 
of our own country. These phenomena, he says, are ^^ widely 
differenV* from those enumerated by the foregoing writers, as 
characteristic of the typhus which they describe ; but whether this 
want of likeness depends upon various modifying circumstances, 
connected with the prevalence of the disease in the two countries, 
or upon an '' intrinsic difference^'^ in their nature, he does not stop 
to inquire. 

The Dublin Journal of Medical Science, for September, 1836, 



256 TYPHUS FEVER. 

contains two short letters, T^ritten by Dr. H. C. Lombard, of 
Geneva, and addressed to Dr. Graves, on the relation of the typhus 
fever of Britain to the typlioid fever of the continent. Dr. Lombard 
had for six years been familiar with the latter disease in France 
and in Switzerland, and in the fatal cases, had invariably found 
the peculiar lesion of Payer's glands. On Dr. Lombard's arrival 
in Glasgow, in 1836, he was -allowed by his friends to examine 
the body of a fever patient, in whom he had said no doubt could 
exist as to the presence of follicular disease. He was not a little 
astonished at finding the elliptical plates wholly unaltered. On 
his arrival in Dublin, he was again furnished with an opportunity 
of making two similsir examinations, — one at the Meath, and one 
at the Hardwicke Hospital, — and here again he was disappointed 
in not finding any lesion of the elliptical plates. Dr. Lombard 
alleo-es that he found the symptoms of the British typhus almost 
identical with those of the typhoid fever of the continent, but he 
immediately proceeds to mention the great difierence in the ap- 
pearance of the eruption in the two diseases, or forms of disease, 
the frequent occurrence of typhus in old subjects, the absence of 
prominent abdominal symptoms, and its strongly marked conta- 
gious character. He does not speak very positively upon the 
subject, but is unwilling to admit that the two diseases are speci- 
fically distinct. 

Dr. Lombard, on his way home, visited the Fever Hospitals of 
Liverpool, Manchester, Birmingham, and London; and on his 
arrival in Geneva, wrote a second letter to Dr. Graves, bearing 
date about one month subsequent to his first communication. At 
Liverpool, Manchester, and London, he found the same state of 
things, as he had seen in Dublin, and Glasgow; prominent cere- 
bral symptoms, an abundant cutaneous eruption, infirequency of 
abdominal disorder, many patients of advanced age, and strong 
evidences of the contagious character of the fever. It does not 
appear, that he witnessed any autopsies anywhere in England. 
At Liverpool, he was told, that ulcerations of the ileum and caecum 
were occasionally, but by no means constantly, met with ; and 
that their frequency varied in different seasons. At Manchester, 
he was informed merely, that the ulcerations of the intestines 
were by no means always to be found in the fatal cases : at Bir- 
mingham, he saw no patients, but was told by the medical attend- 
ants of the fever wards in the General Infirmarv, that in exami- 



DIAGNOSIS.— HISTORICAL. 257 

nations, after death, ulcerations of the lower part of the ileum 
were always present. At the London Fever Hospital, he saw 
but very few patients, but concludes from Dr. Tweedie's researches, 
that ulcerations in the lower part of the ileum are not to be found 
in more than one-fourth of the fatal cases; and that their frequency 
varies with different seasons: it being much greater in autumn 
than at any other period of the year. 

This constitutes the whole sura and substance of Dr. Lombard's 
personal knowledge of the typhus fever of Great Britain. In his 
second letter, he expresses, very decidedly, the opinion, that there 
are two distinct and separate fevers prevalent in Great Britain; 
one of them identical with the contagious typhus, the army and 
jail fever, of the French pathologists ; the other a sporadic disease, 
identical with the typhoid fever, or dothinenteritis, of the French. 
He considers L-eland as the source of the former disease ; and 
supposes it to be carried by the Irish, in their annual migrations, 
to the several large towns, and cities, of the sister island.^ In 
Glasgow, it constitutes, he says, one-third of the total number of 
fever cases; in Dublin, much less; and in London, one-fourth; 
these proportions varying, in different seasons, but being greatest 
in autumn. 

IMany of the suggestions contained in these letters, were, at 
the time when they were made, exceedingly important ; and it 
seems somewhat singular, that they should not immediately have 
received a greater degree of attention from British observers. 
The conclusions, however, in regard to the exact degree of pro- 
portion in the prevalence of the two fevers, or forms of fever, in 
different cities of Great Britain, and in regard to the exclusive 
origin of typhus in Ireland, and its subsequent diffusion through 
Scotland and England, are, to say the least of them, premature, 
and gratuitous. This precipitancy of judgment would seem to 
be a prominent characteristic of Dr. Lombard's mind ; for we find 
him, in 1839, imagining that he had demonstrated the existence 
of a new disease ; a true bilious fever, differing both from typhoid, 
and from the bilious remittent, fever; from this worthless and 
utterly inadequate evidence, — the occurrence of two cases of pro- 

1 As an offset to this opinion it may be remarked, that Dr. Barker, many years 
ago, attributed the great increase in the prevalence of fever, v^^hich took jjlace 
throughout Ireland, during and after the year 1810, to its introduction from the 
continent by the return of the Walcheren troops, and in other ways. 

17 



258 TTPHrS FEVER. 

longed, bilious Yomiting and purging, one of mem, in a female, 
seventy-tbar years old, tbe other, in a female fitty-eight years old; 
both terminating fatally; in only one of which, was there an ex- 
amination of the body, and in this, no apparent lesion of any of 
the oro-ans-l- In toI. xlviii. of the Edinburgh Medical and Sur- 
gical Journal, there is a very interesting notice of several papers, 
by recent German writers, on the abdominal typhus of that coun- 
try, in which the question of the identity of this disease, clearly 
and manifestly typhoid fever, with the true British typhus is at 
least admitted, to be a legitimate subject of doubt, and of further 
investigation. Macculloch insists yery strongly that the typhus 
mitior of Cullen, the low, nervous fever, as it is commonly called, 
is essentially different from true contagious typhus.^ 

Tae most important document, in the history of this investiga- 
tion, is the paper of Dr. Gerhard's, to which reference has been 
so frequently made. The leading facts contained in that paper, 
so far as they bear upon the question before us, have already been 
embodied in the preceding account; it can be hardly necessary, 
therefore, to repeat them here. It is enough to say, that the dis- 
ease observed by Dr. Gerhard, and Dr. Pennock, prevailed some- 
what extensively, there having been admitted to the hospital with 
it, between March, and August, 1S36, nearly two hundred and 
fifty patients ; that it corresponded, very exactly, in its symptoms, 
to the true typhus ; that it was clearly transmissible by contagion ; 
and that the elliptical plates, and the mesenteric glands were 
found uniformly free from the lesion of typhoid fever. Dr. Ger- 
hard, and Dr. Pennock had both been familiar \vith the latter 
disease, and they were struck with the wide difference between it 
and the typhus of 1836 ; and to them belongs the credit of having 
first fully pointed out, and clearly established, the most prominent 
and essential points of dissemblance between the two diseases. 

Dr. Staberoh, of Berlin, after four or five years' study of continued 
fever in \ ienna, and Paris, and after passing six months in Great 
Britain, where he had extensive opportunities tor observing both 
typhus, and typhoid, fever, adopted the doctrine of the specific 
difference between the two diseases.^ 

Mr. Henry Kennedy, in a paper contained in the Dublin Journal 
ibr March, 1838, says, that while his mind was in a state of sus- 

' Gazette a'ledicale, March, 1S39. 2 IVIaccullocK on ^laxsh Fever, p. 35. 

3 Dublin Jour, of 3^l£d. Science. Julv. 1S38. 



DIAGNOSIS.— HISTORICAL. 259 

pense, in regard to the conflicting opinions of the French and 
British pathologists, as to the connection between intestinal le- 
sions, and continued fever, an opportunity was presented to him 
of seeing the common fever of Paris, and of Geneva ; and to his 
surprise he found it in many particulars different from the typhus 
of his own country. Two years of subsequent uninterrupted 
study of the subject convinced him, " that the fevers of the two 
countries are of different types, and that typhus may in the great 
majority of instances be distinguished from the gastro- enteric 
fever of the French." 

In the early part of 1839, Dr. George C. Shattuck, Jr., of Bos- 
ton, had an opportunity of studying, under favorable circum- 
stances, a small number of cases of continued fever in England. 
Dr. Shattuck had been already familiar with the typhoid fever of 
Paris, where he had then recently been engaged in its investiga- 
tion, under Louis. It was at the particular request of Louis, as 
well as from his own warm interest in this very important ques- 
tion of diagnosis, that his observations were made. He saw 
thirteen cases of continued fever, at the London Fever Hospital, 
where, he says, through the kindness of Dr. Tweedie, the attend- 
ing physician, and of Mr. Goodfellow, the resident medical officer, 
every facility for the examination of the patients, and for anato- 
mical researches, w^as afforded him. An account of these cases 
was communicated, by Dr. Shattuck, to the Medical Society of 
Observation of Paris. They were subsequently made the ground- 
work of an elaborate memoir of nearly seventy pages, by M. 
Valleix, which is contained in the October and November num- 
bers of the Archives Generates de Mededne, of Paris, for 1839. 
Dr. Shattuck's own history of his observations was published in 
the Medical Examiner for February 29th, and March 7th, 1840. 
As M. Valleix's analysis and comparison are founded entirely 
upon the cases furnished by Dr. Shattuck, it is unnecessary to 
take any further notice of the former, excepting to say, that the 
author arrives at the conclusion, that the typhoid, and typhus, 
fevers are both to be met with in England, and that they are dis- 
tinct diseases. 

Dr. Shattuck's paper contains histories, more or less complete 
and extensive, of six of the thirteen cases. The first of these 
was, clearly enough, identical with the typhoid fever of Paris, and 
New England. The patient was twenty-two years old; and in 



260 TYPHUS FEVER. 

addition to many symptoms, common to both diseases, there were 
meteorism, and diarrhcea ; and on examination, after death, the 
characteristic lesion of the elliptical plates, and the mesenteric 
glands, although moderate in extent, was present. Nothing is 
said, in the report of this case, of any cutaneous eruption. The 
second case corresponded, in its most prominent features, to the 
typhus fever of the Irish writers, and of Dr. Gerhard. There was 
no meteorism, and the skin of the trunk and limbs was covered 
with numerous spots, of a dark red color, imperfectly disappearing 
on pressure, of the size of the head of a pin, or of a small pea, 
grouped together. The elliptical plates, and the mesenteric 
glands, were in a healthy condition. In the third case, the disease 
does not seem to have been so clearly marked. The symptoma- 
tology was rather that of typhoid, than of typhus, fever ; but 
along with four or five lenticular rose spots on the abdomen, 
slightly raised above the surface of the skin, and disappearing on 
pressure, there were other spots grouped together, not raised above 
the surface. The history of the case is not very full. The fourth 
case was evidently enough, I think, one of typhus fever. The 
abdominal symptoms were very slightly marked ; there were red- 
ness, and suffusion, of the eyes, and the deep red, grouped erup- 
tion over the skin of the body and arms. In the fifth case, which 
is briefly described, the diagnosis is uncertain. There were no 
abdominal symptoms, and both eruptions seem to have been pre- 
sent, as in the third case. The sixth and last case is reported 
more at length. It resulted fatally, and after six days of mild 
and damp weather, the abdominal viscera were removed from the 
body and examined. There was no appreciable alteration of the 
elliptical plates, or the mesenteric glands. Dr. Shattuck seems 
disposed to consider this case as one of typhoid fever. There 
was diarrhoea, and the abdomen was somewhat swollen. It was 
tender on pressure, but so also were the limbs. There were a 
few lenticular rose spots upon the abdomen, but they were fol- 
lowed by an abundant petechial eruption, of a deep red color, 
scarcely disappearing on pressure, not raised above the skin, and 
extending over the body and limbs. It ought to be added, that 
this patient, who, up to that period, had been in good health, was 
seized with the disease, the day after she had been employed in 
washing the clothes of the porter of the hospital, who had just died 
of fever. 



DIAGNOSIS.— HISTORICAL. 261 

It is not my purpose to follow out in detail Dr. Shattuck's 
analysis, and comparison, of the phenomena presented in his 
cases. Throwing out one of the cases, he divides the remaining 
twelve into two series, — the first corresponding in its general fea- 
tures to typhoid fever, — and the second distinguished from the first 
by the absence of abdominal symptoms, of the lesions of the 
glands of Peyer, by presence of a peculiar eruption, and by the 
liability to the disease on the part of older persons. The first 
series consists of three cases, one of which terminated fatally; the 
second consists of nine cases, four of which were fatal. 

These observations, although few in number, are very valuable. 
They were made under interesting circumstances, by a competent 
and accomplished observer; and they show, conclusively, so far 
as they go, that many cases at least, of the continued fever of 
Britain, may readily be distinguished, during life, from the typhoid 
fever of France and our own country ; and that they are not cha- 
racterized by the same anatomical lesion which is present in the 
latter. 

The forty-fifth volume of the Edinburgh Medical and Surgical 
Journal contains some observations on Continued Fever, as it 
occurs in the city of Glasgow hospitals ; in the form of a letter to 
the editors, by Dr. Robert Perry. The only thing in these obser- 
vations, which it is at all important for me to notice, is the view 
which Dr. Perry takes of the relations between dothinenteritis, and 
typhus fever. He looks upon the intestinal lesion as an accidental 
complication of typhus fever, and not less frequently, also, of 
small-pox ; and says, that in the latter disease, the morbid ap- 
pearances in the intestine are the same as those which occur in 
dothinenteritis itself, which disease, he says, may also exist as an 
affection per se, characterized by its peculiar symptoms ; and 
from his enumeration of these symptoms, it is very certain, that 
he has reference to typhoid fever. It is quite clear that Dr. Perry's 
observations, notwithstanding their extent, and he speaks of hav- 
ing made three hundred autopsies, have not been sufficiently 
accurate and discriminating to aid us much in the settlement of 
nice and difficult questions of diagnosis, like the one under con- 
=-ideration. 

In the month of April, 1840, Dr. Alexander P. Stewart read, 
before the Parisian Medical Society, a valuable paper, upon the 
question of the identity, or non-identity, of typhoid, and typhus. 



262 TYPHUS FEVER. 

fevers. This paper is contained in the Edinburgh Medical and 
Surgical Journal, for October, 1840. Dr. Stewart says, that 
when he began, in 1836, the practical study of fever, he was 
much struck with the simultaneous occurrence, in the wards of 
the Glasgow Fever Hospital, of two sets of cases, in which the 
symptoms, however little most of them might seem to differ, when 
viewed individually, presented, when taken collectively, characters 
so marked as to defy misconception, and to enable the observer to 
form, with the utmost precision, the diagnosis of the nature of the 
disease, and the lesions to be revealed by dissection. In one class 
of cases, the affection, when it was mild in its character, and of 
short duration, was not attended by any eruption; while those 
cases, in which it was fatal, presented an abundant and generally 
a profuse eruption ; but in the other class of cases, which equally, 
and even in a much higher proportion, went on to a fatal termi- 
nation, there was rarely any, and, at most, only a very scanty 
eruption. Dr. Stewart also noticed, that the disease, in the latter 
class of cases, was much more gradual in its progress, and pro- 
longed in its duration, than in the former ; and, finally, to com- 
plete the contrast, already so striking, dissection proved the exist- 
ence, in the one disease, of most extensive local lesions, and in 
the other, the absence of all prominent local lesions whatsoever. 
Dr. Stewart then proceeds to consider, at some length, the lead- 
ing features of difference between these two diseases, in regard to 
their origin, their proximate causes, their course and duration, 
some of their symptoms, some of their anatomical lesions, and 
their treatment. He considers it settled, that the poison of typhus 
is frequently generated by the crowding together of great num- 
bers of individuals in close and unventilated places, while the 
similar origin of typhoid fever is, at least, very doubtful; that 
typhus is eminently contagious, while typhoid fever is so to a 
much more limited extent, and only under peculiar circumstances; 
that the mean duration of typhus is much less, than that of typhoid 
fever ; that relapses are as common in the latter as they are rare 
in the former; that well marked crises occur frequently in typhus, 
but never in typhoid fever; that the symptoms connected with 
the abdomen, and that the cutaneous eruption are very dissimilar 
in the two diseases ; that there is no resemblance between the 
anatomical lesions ; and that the treatment which may be best 
adapted to one disease may be most unsuited to the other. 



DIAGNOSIS.— HISTORICAL. 263 

Dr. Stewart had studied typhus fever in Glasgow, and typhoid 
tever, both in GLisgow and Paris, before the publication of his 
very interesting and instructive paper ; and many of his conclu- 
sions are founded upon his own careful observations of the two 
diseases. I cannot help remarking, that it is somewhat singular, 
that amongst the many observers, whom he quotes in support of 
the views, which it is the object of his paper to establish, and to 
illustrate, he should have wholly overlooked the researches of our 
countryman, Dr. Gerhard, who by his history of the epidemic 
typhus of Philadelphia, in 1836, had done more, than any other 
observer, towards determining the very questions, which consti- 
tute the subject of Dr. Stewart's essay. 

It is proper that I should notice here, very briefly, some re- 
marks upon this subject, appended to an elaborate prize essay, 
on the sources and mode of propagation of the continued fevers of 
Great Britain and Ireland, by Dr. William Davidson, of Glasgow. 
Dr. Davidson institutes a loose general comparison of the symp- 
toms of the two fevers, and pronounces them nearly or quite iden- 
tical. He gets over the difference in regard to diarrhoea, by 
attributing its frequency in the typhoid fever of Paris to the 
neglect of the French to use purgatives, and to the consequent 
irritation of the intestinal mucous surface, by the retained feces. 
The seeming difference in relation to the comparative frequency of 
meteorism in the two diseases, he explains by supposing that the 
French apply this term to much slighter distentions of the abdo- 
men, than would justify the English in its use. He quotes Dr. 
Lombard to show, that the symptoms of the two fevers are the 
same. Dr. Lombard's opinions upon this subject may be very 
sound ; but we have already seen, that his observations, so far as 
the symptoms of the diseases are concerned, were too few and too 
hurried to be of any value w^hatever. Dr. Davidson admits, that 
the intestinal lesion is very rare on his side of the channel, and 
almost invariable on the other; but this circumstance he seems 
to suppose may be accounted for, by differences of climate, diet, 
habits, &c. So far as Dr. Gerhard's researches are concerned, 
in relation particularly to the lesions, he begs the question entirely, 
by implying, that the disease which he describes, could hardly 
have been British typhus, since fifty consecutive inspections of 
that disease could not be made without finding one decided in- 
stance of alterations in the intestinal follicles. He also misun- 



264 TYPHUS FEVER. 

derstands Dr. Gerhard, in representiDg him as resting his diag- 
nosis of typhus almost exclusively on the absence of the lesion, 
and as admitting the almost perfect identit^^ of the symptoms of 
the two diseases, neither of which does Dr. Gerhard do. In con- 
clusion, he admits that 'Hhe strength of Us argument ^ in favor 
of the identity of the two fevers lies in the fact, that it has been 
admitted, that cases of tj-phoid fever have occurred with no intes- 
tinal lesion. After the full exposition, which has been given, of 
this particular point, and the extreme infrequency, which has been 
shown, of the occurrence itself, it is obvious though, that the ar- 
gument deduced from it is characterized by anything rather than 
strength. 

In an inquiry into the sources and mode of action of the poison 
of fever, by Dr. Alfred Hudson, physician to the Navan Fever 
Hospital, republished in this country, in connection with the 
above mentioned Essay, in Dr. Dunglison's Medical Library, the 
author takes the opposite view of this subject. He recognizes 
the essential dissimilarity of typhus, and typhoid, fevers; and 
gives the valuable results of his own personal observations in the 
following words: — "In the Xavan Fever Hospital, there have 
been for the last seven years almost always two distinct forms of 
fever present ; one or the other occasionally preponderating, so as 
at times nearly to exclude the other. Thus, for the first three years, 
the prominent features were pain, tenderness and meteorism 
of the abdomen, diarrhoea, and not unfrequently these symptoms 
combined with catarrh; several cases of perforation of the ileum 
occurred towards the close of this period; petechias were not 
frequent, and were late in their appearance, and we had few in- 
stances of communication by contagion. During the three fol- 
lowing years, a highly contagious fever prevailed, and the s^inp- 
toms and treatment were completely different; delirium, subsultus, 
dysphagia, being the ordinary symptoms, and diarrhoea being 
rarely met with ; nearly every case presented the measly efflores- 
cence, and instances of contagion were as numerous, as they had 
been rare, previously. During the present summer, the prevailing 
tj-pe has been the abdominal fever of the first period, and instances 
of tj'phus are infi-equent, certainly not a fourth of the whole, and 
sent exclusively from a district in which the epidemic of last year 
still lingers. 

At a meeting of the Dublin Pathological Society, January 3 1st, 



DIAGNOSIS.—HISTORICAL. 265 

1846, Dr. Greene stated that whenever he met with the phenomena 
so accurately described by Louis, as belonging to typhoid fever, 
he invariably concluded that follicular disease of the intestine was 
present.^ 

Many of the French WTiters upon typhoid fever, of the present 
period, seem to incline to the opinion, that the camp, and jail 
fever of former observers, and the typhus of the British authors, 
are identical with that of their own country. In 1837, the Royal 
Academy of Medicine crowned w^ith one of its prizes a memoir, 
by M. Gaultier de Claubry, upon the differences, and analogies, 
between typhoid, and typhus fevers; the conclusion of which 
memoir is in these words: — "There are no means of distinguish- 
ing typhus, from typhoid fever, in relation either to the lesions, or 
the symptoms, of the two diseases." The same writer, as late as 
October, 1839, says, that the identity of the two diseases is hence- 
forth put beyond doubt. It is proper to add, that at the same 
time, the academy bestowed a second prize upon another memoir 
upon the same subject, in which the opposite doctrine was advo- 
cated. In regard to the memoir of Gaultier de Claubry, it is 
important to state, that his object is to demonstrate the identity 
of the typhoid fever of Paris, and the jail, army, and camp fevers, 
of the continent of Europe. He formally puts aside the British 
typhus. He insists, as though it was one of the strongest points 
in his argument, upon the constant presence, in the continental 
jail and camp fever, of the lesion of Peyer's glands. This ques- 
tion has since been very fully discussed by the Royal Academy. 
I only wish it to be clearly understood that the question is quite 
different from the one now before us. 

In the Archives Generates de Medecine for January and Feb- 
ruary, 1842, there is an interesting history of a supposed epidemic 
typhus fever, which prevailed at Rheims, between the first of 
October, 1839, and April, 1840; by M. H. Landouzy; in the 
course of which, the author considers, at some length, this ques- 
tion of the differences, and resemblances, betw^een typhus, and 
typhoid fevers. The epidemic was confined to the inmates of a 
certain quarter of the prison of Rheims, and to those whose occu- 
pations brought them into close connection with the patients, after 
they were removed from the prison to the hospital, where they 

* Dublin Hospital Gazette, March, 1846. 



266 TYPHUS FEVER. 

were all immediately and successiyely taken on the appearance 
of the fever. The entire number of cases was one hundred and 
thirty- eight ; one hundred and three of which were amongst the 
inmates of the prison ; the remaining thirty-five consisting of phy- 
sicians, medical students, nurses, and others, connected with the 
hospital, where the patients were treated. 

There are some circumstances, which render the history of this 
particular epidemic one of great value. I ^vill mention only one, 
and that is, that all the cases came under the observation of the 
medical attendants, immediately on the commencement of the 
disease. This is rarely the case, in hospital practice ; and, in the 
present instance, it afforded a good opportunity for the study of 
the earhest phenomena of the disease. I shall give a brief abstract 
of its history. 

Amongst the first and most prominent symptoms of the epidemic 
was stupor. It frequently showed itself as early as the second or 
third day, and continued, until it was lost in coma, or delirium. 
M. Landouzy does not mean by this stupor any degree of mere 
somnolence, or coma. He thinks, that it differs from either of 
these states. The expression of the countenance is that of half- 
demented, and stupid, astonishment. This is the stupor attonitus 
of Foes. In half the cases, it was strongly marked; in the other 
half, it was slight in degree. M. Landouzy thinks, that it comes 
on earlier, and is more striking, than the same symptom in typhoid 
fever. True somnolence and coma appeared in a certain number 
of cases, later in the disease, often about the tenth day. Profound 
coma, so that the patient could not be roused, existed in only 
twelve cases. Delirium was very common, usually making its 
appearance between the third, and the eighth day. It was gene- 
rally low, and muttering, in its character, and, in fatal cases, it 
continued until death. Headache was uniformly present at the 
commencement of the disease. It was, for the most part, dull 
and heavy, and felt especially over the eyes. It continued for an 
uncertain period of time, gradually disappearing, or losing itself 
in coma, or delirium. Suhsultus tendinum was common, and 
strongly marked, in grave cases. Redness of the eyes, tinnitus 
aurium, and deafness, were present in a certain proportion of 
cases, but differed in no obvious paiticulars from the same symp- 
toms in typhoid fever. There was great loss of muscular strength, 
from the beginning of the disease. 



DIAGNOSIS.— HISTORICAL. 267 

In every case, except the first, which was not carefully ex- 
amined, there was an abundant cutaneous eruption, consisting of 
small spots, or ecchyraoses, as M. Landouzy calls them, of a red, 
violet, or black, color, not elevated above the skin, and not dis- 
appearing on pressure. They were always found on the chest, 
often also on the abdomen, and, in some cases, they extended to 
the arms, and legs. They commonly showed themselves about 
the fourth or fifth day, and gradually faded away between the 
tenth and the eighteenth. They were abundant and confluent, 
in proportion to the gravity of the disease. The bodies of the 
sick exhaled a strong, offensive odor, resembling that of mice. 

In regard to the absence of appetite, to thirst, the state of the 
lips, tongue, and mouth, nothing special was observed, differing 
from what occurs in typhoid fever. Nausea w^as present at the 
commencement of the disease, in all the cases. Meteorism, and 
abdominal pains, were uniformly absent. There was diarrhoea at 
the beginning of the disease in only four cases. In all the others, 
there was no apparent disturbance in the functions of the intesti- 
nal canal. The bowels were more inclined to constipation, than 
to looseness. 

A distinct, well-marked, sibilant rhonchus was present in all 
the cases. There was nothing remarkable in the frequency of the 
pulse. It was full and large, and, at the commencement of the 
disease, resisting. There was nothing unusual in the appearance 
of the blood. Epistaxis occurred in only eight cases. The tem- 
perature of the surface was uniformly elevated ; the heat was dry 
and burning. In no instance was there gangrene of any part of 
the body. 

The contagious character of the epidemic was very manifest, 
as has ^ready been intimated. Three physicians, six medical 
students, twelve nurses, and other attendants on the sick, after 
they had been transferred from the prison to the hospital, amount- 
ing in all to thirty-five, contracted the fever. Amongst these, 
there w^ere nine deaths, or one in four, nearly; while amongst the 
one hundred and three prisoners, there were only eight deaths, or 
one in thirteen, nearly. None of the nurses, who had had typhus 
fever, in 1814, were attacked with the disease ; but, two medical 
students, and one physician, who had had typhoid fever, the 
former, six months, and the latter, twenty years, previously, suf- 
fered very severely. 



268 TYPHUS FEVER.- 

Of one hundred and four patients, in whom the age was accu- 
rately ascertained, sixty were from fifteen to thirty years old ; 
thirty-six were from thirty to fifty ; and eight were from fifty to 
seventy. 

The quarter of the prison in which the disease commenced, and 
to which it was almost exclusively confined, was originally in- 
tended to accommodate from eighty to one hundred inmates; it 
had usually contained from one hundred to one hundred and 
twenty; at the time when the epidemic appeared, its population 
amounted to one hundred and eighty. 

Many, indeed most, of the foregoing circumstances, in the his- 
tory of this local epidemic, correspond to the phenomena which 
we have found to occur in typhus fever. But, according to M. 
Landouzy, in the six autopsies which were made, the intestinal 
lesions, characteristic of typhoid fever, were present. The ellip- 
tical plates were either thickened, and elevated, or they were the 
seats of ulcerations ; and the mesenteric glands, corresponding to 
them, were enlarged. The spleen was not increased in size in 
any of the cases ; in four it seemed somewhat softened. 

In this epidemic, if entire reliance is to be placed upon the ob- 
servation of its historian, there seems to have been a union, in the 
same cases, of many of the elements, which are generally found 
confined, either to one, or the other, forms of continued fever. 
The symptoms of contagious typhus were found in connection 
with the follicular lesion of typhoid fever. Is it possible, that, 
even admitting the two diseases to be essentially dissimilar, under 
certain circumstances the causes of both may be so commingled, 
as to give rise to a mixed disease, in which there is a combination 
of the elements of both ? Let it be remembered, that this, as well 
as all analogous questions, is to be determined, not by. a priori 
reasoning, however plausible and ingenious, but by simple, care- 
ful, rigorous observation. M. Landouzy, in the case before us, in 
the spirit of a true and sound philosophy, says, that we must await 
the results of ulterior observation before we shall be able to settle, 
definitively, this great question in regard to the identity of these 
several forms of fever. " In effect," he adds, "if in all future 
epidemics of the typhus of camps, of jails, of hospitals, &c., we 
find, as in that of Rheims, complete absence of disease of the 
spleen, and great differences between the symptoms and those of 
typhoid fever, we must confine ourselves to the conclusion, that 



DIAGNOSIS.— HISTORICAL. 269 

typhus and typhoid fever are analogous, and not identical, dis- 
eases. If, on the contrary, Ave find, that in one epidemic, diar- 
rhoea is absent, in another, the petechial eruption, in another the 
rose spots, and so on, we must conclude, that these diflerences 
depend only upon variations in the action of the epidemic cause, 
and that the disease is, in its nature and essence, identical with 
typhoid fever." M. Landouzy's conclusion, in regard to the 
epidemic, which constitutes the subject of his memoir, is, that the 
resemblances between it and typhoid fever are so numerous as to 
induce him to look upon the two diseases as analogous; but that 
the differences between them are also too numerous to allow him 
to regard them as identical. 

I shall conclude this historical survey of facts and opinions, 
bearing upon the question of diagnosis before us, by a short re- 
ference to an article contained in the July and October numbers 
of the British and Foreign Medical Review for 1841. This arti- 
cle contains a pretty full exposition of the subject under considera- 
tion, and abating some mere smartnesses in its criticisms of Chris- 
tison, Gerhard, Lombard, and Staberoh, it is written in a good 
spirit, as well as with fairness and ability. Its noble tribute to 
Louis has already been noticed. The writer of the paper, after 
an examination of all the accessible and valid evidence in the 
case, comes to the conclusion, that the contagious typhus of Great 
Britain, and the typhoid fever of France, are different varieties, 
only, and not distinct species, of disease. I have already gone 
over nearly all the ground occupied by this writer; I shall have 
occasion, therefore, to notice only two or three of his statements 
and opinions. The most important of these, in its connection with 
the diagnosis of the two diseases, is this; in his tabular compari- 
son of typhoid fever, and typhus, he sets down, so far as the ab- 
dominal lesion is concerned, as typhus, all the cases of fever, oc- 
curring in Britain ; thus settling before-hand the very question at 
issue, in relation, at least, to one of its elements. The writer ad- 
mits, that the two forms of fever may generally be distinguished 
during life ; but alleges, that there are cases, in which such dis- 
tinction cannot be established. The number and authenticity of 
these latter, are, certainly, thus far, very limited ; and if a difference 
of symptomatology, sufficiently marked to he generally and readily 
recognized, corresponding constantly with a most important differ- 
ence in the state of certain organs, found in fatal cases, is not ade- 



270 



TYPHUS FEVER. 



quale to constitute separate diseases, it is not easy to see in what, 
radical nosological distinctions are to he found. In order to account 
for the great differences in the appearances of the eruptions in the 
two diseases, the reviewer suggests the hypothesis, certainly im- 
probable and gratuitous enough, that the lesions of the skin, and 
of the intestine, maybe supplementary of each other; a most 
facile method, assuredly, of disposing of a difficulty. 

Such is the history, as full and fair as I have been able to make 
it, of the recent investigations in regard to the relations between 
typhoid, and typhus, fevers. Excepting those of M. Landouzy, 
it seems to me, that they all go to show, that the two diseases are 
radically, and essentially, dissimilar. I have no wish, whatever, 
to make out a case in this matter. I would avoid, scrupulously, 
anything like special pleading. The truth, as Louis's motto from 
Rousseau says, is in the things, in the facts and their relations, 
not in my mind, which attempts to judge and to interpret them. 
I am anxious, only, that this truth, be it what it may, should be 
ascertained. That this has been done, absolutely, and definitively, 
I do not pretend. That typhoid, and typhus, fevers are, clearly 
and unequivocally, fundamentally distinct diseases, may not have 
been positively demonstrated. I admit, that the paper of M. 
Landouzy throws some doubt upon the question. But, as has 
been remarked before, whether the two diseases be or be not specifically 
and nosologically unlike each other, it is equally important, that 
the wide differences which confessedly do exist between them should 
he pointed out, and their real relations established. This I have 
endeavored, so far as the present state of our knowledge could 
enable me, faithfully and truly to do. 

In regard to the identity of the former camp and jail fevers of 
the European continent, either with typhoid fever, or with typhus, 
it is not possible to come to a positive conclusion. Louis thinks, 
that they were typhoid ; others think, that they were typhus. It 
is probable, as I have already said, that both forms of fever may 
have prevailed. At any rate, the descriptions given of them are 
generally so imperfect, that it is wholly impossible now to decide 
this question with any degree of certainty. It is quite as well, 
perhaps, not to attempt its solution at all. 

A friendly critic, in an American medical journal, expresses 
some surprise at the opinions contained in the above paragraph. 
He thinks there can be no doubt that the continental camp and jail 



DIAGNOSIS.— HISTORICAL. 271 

fevers were true typhus, differing essentially from typhoid fever. 
Since the publication of my first edition, I have read carefully 
the prize memoir of Gaultier de Claubry, upon this question, and 
I heard a part of the very full and animated discussions, of which 
it has recently been the subject in the Royal Academy of Medi- 
cine, at Paris. These investigations have fully confirmed me in 
the soundness of the foregoing conclusions. It is impossible to 
read the detailed and elaborate work of M. Gaultier de Claubry, 
without being convinced, that many of the epidemics, prevailing 
in the armies and prisons, throughout various portions of the con- 
tinent, from 1804 to 1814, corresponded in all respects to typhoid 
fever ; while, in other instances the disease was true Irish typhus. 
In my Essay, on the Philosophy of Medical Science, I have 
endeavored to ascertain and to point out the true principles of 
nosological diagnosis ; I have attempted to lay down the rules by 
which we ought to be governed in deciding upon the individuality 
of any given disease. I do not propose, here, to enter again upon 
the discussion of this subject; I wish merely to say, that, the ele- 
ments which typhoid and typhus fever possess in common, are 
neither more numerous nor more striking than those which are 
possessed in common by many other diseases, admitted to be essen- 
tially dissimilar from each other. Would not small-pox be constantly 
confounded with typhus, if neither of these diseases w^as marked 
by any distinctive cutaneous eruption ? In a note to the chapter 
in my essay, just referred to, I have said: — "Let me here add, 
that this question, of the essential likeness, or unlikeness, of these 
two diseases, — typhus, and typhoid fever, — one of the most im- 
portant and interesting questions of specific diagnosis, that has 
ever occupied the attention of physicians, — if submitted to the 
test of the principles which I have laid down, and fairly tried by 
them, — cannot fail, I think, to be settled in favor of the doctrine 
of their fundamental dissimilarity. The two diseases will be found 
to approach each other, very closely, in the possession of those 
morbid processes and phenomena, — I mean general fever of the 
typhoidal type, certain changes in the composition and quality of 
the blood, and certain nervous symptoms, — which are common to 
many diseases, and, for this reason, of hut small value as diagnostic 
or distinctive characters ; while they are separated clearly and 
broadly from each other, by the presence in one, and the absence 
fcom the other, of very strongly marked and constant anatomical 



272 TYPHUS FEVER. 

lesions ; and of groups of symptoms, equally striking, constant, 
and characteristic. Any principles of diagnosis, or any rules of 
reasoning, that make true typhus fever, and typhoid fever essential- 
ly one specific disease, will make small-pox, and oriental plague, 
also, nothing but varieties, or modifications, of the same single 
disease. This result vrill be found to be absolutely unavoidable. "^ 

It is now five years since the publication of the first edition of 
my work on fever. This question, of the true relationship between 
typhus and typhoid fever, still remains a matter of controversy. 
It has been extensively discussed, both in England and France, 
and the opinion of the profession is still divided. I have watched 
this discussion closely and dispassionately, and I have seen nothing 
to induce me in any degree to modify the judgment which I had 
formed and expressed; unless, indeed, it be in withdrawing alto- 
gether the slight doubt, or qualification, with which it was ac- 
companied. The more I have studied the subject, and the more 
I have reflected upon it, the more thoroughly have I been con- 
vinced that the objections to the opposite doctrine are conclusive 
and insuperable, and I cannot doubt that such will be the final 
verdict of science in the issue before us. 

In connection with this subject, I have the pleasure of publish- 
ing the following interesting letter from Dr. William Power, of 
Baltimore, dated September 4th, 1847. "The questions you ask 
have interested me very deeply; and this summer for the first 
time I have had ample opportunity to fix definitively my own 
opinions. WTiat I write you now resumes the opinions also of 
Drs. Chew and T. Buckler, who saw the disease throughout 
its whole visitation in this city ; nor do I know of one gentleman 
who had any opportunity of studying it here who differs from us. 

"We have had for the last fourteen months, an epidemic of ty- 
phoid fever in Baltimore. The wards of the almshouse, and in- 
firmary, have constantly contained a large number of cases of this 
disease, presenting nothing remarkable, save that the cases had, 
as a general rule, more of the adynamic type than in former 
years, and required and bore more stimulation. Early in May, 
two vessels arrived, brino-ino; Irish immicrrants : one from Liver- 
pool, the other from the South of Ireland. Other vessels suc- 
ceeded these; so that upwards of two hundred cases were treated 

> Essay, etc., pp. 140-141. 



DIAGNOSIS.—HISTORICAL. O73 

at the infirmary, and upwards of eighty at the almshouse. These 
cases were typhus, so exactly corresponding with Gerhard's de- 
scription of the Philadelphia epidemic of 1836, that I am con- 
strained to say, I know of no better portraiture of any disease, than 
that which he has given us of typhus fever. I made or assisted 
at twenty. six post-mortem examinations ; in not one did I see any 
trace of the peculiar lesion. In nine of those who died, having 
loose bowels during life, we found either the lesions of dysentery, 
or of diffused muco-enteritis ; no mesenteric alteration in any 
case. The parenchymatous organs and mesenteric vessels were 
congested with a dark fluid blood; and the condition of the spleen, 
bronchial mucous membrane, lungs, and brain resembled what 
we find in congestive remittent, or typhoid, cases. The stomach 
was uniformly more altered, and presented deeper traces of in- 
flammation, than in typhoid fever. We had fourteen autopsies of 
typhoid fever, during the same period, and it thrice occurred that 
we had the bodies opened side by side for the sake of comparison 
made at the time. 

The mode of access, facies, march, eruption, symptoms, treat- 
ment, and convalescence are all diflferent between the two dis- 
eases. We had both forms of fever at once under observation, 
German immigrants, and domestic patients with typhoid, and 
Irish, and English, with typhus. Nay, more than this, four of the 
seamen of the Rio Grande, a vessel which brought seventy cases 
of typhus, had true typhoid fever, and several of the steerage pas- 
sengers had the same disease. There was no mistake in the 
diagnosis in any case where the issue w^as fatal, as proved by the 
autopsy; and in the successful cases, the diflference of eruption, 
diarrhoea, meteorism ; the peculiar nervous symptoms ; the greater 
emaciation ; bed sores, which were so rare in the worst cases of 
typhus, that I saw but two, made the diagnosis simple to every 
clever student. The effect of a full stimulant treatment made the 
difference still more obvious. In short, we have here in Baltimore, 
no doubt, but the fullest conviction, of the non-identity of the two 
diseases. 

Furthermore, there is the undoubted contagiousness of typhus. 

Two of the Sisters of Charity at the infirmary — one of whom died 

— and three out of five resident students took the disease. Four 

of the hospital assistants, and several of the inmates of the alms- 

18 



274 TYPHUS FETES. 

iousc ^f.'r / -: :^T ~ -rv cases occurred also in the city, where 
direct in: r : : : : s 7 : . -ays be traced and prored. 

HtTt .5 riiciier inteiesting order of facts. A German had 
- . ^ui was eighty days in bed under Dr. Buckler; he 

:- ^ 3 ::_! r^s acting as hospital assistant; intending the 
5 £ 1:^: 1 5 r "5 5r Zt^ '1 ti/phus, Two yeaTS ago, Dr» 
t : : : . . „ i: :i :.ii5 .ir ?- severe attadc of tjfphoid fecer. 
Hr 5 :::::::ri r^s: t sician at the new quarantine hos- 

-.-:.■. --.:.-:r ::... ".lisr :.\5i5 ::.-. :. :~ sent. He took the fever and 
i:^ ; 5: ~-z^; — '-^ — -^- ^i— liiQg young man I hare ever 
k. ~ :.il^ whose loss has filled us all with grief. Again, one of 
:_- ._::_:^til:s who came near dying in May last, with typhus, is 
i: ::::5 -f 77 -loment at the point of death, with typhoid fever. 

Tliere is as much difoence in my mind between the two dis- 
t?.5 75. ~ 5 there is between measles and scadatina. Huxham has 
'zzvi':vL.ij drawn the distinction between the slow nervous, and 
n :■.'. \ ^ :_ : r_ : . : r ^ers ; excepting the new lights we haTe in pathology, 
~- :.: !:" r :3 wiiat he has said. Corrigan, in Dublin, 

stts _r _ "r.T :t r:ween what he calls enteric, and typhus, 
feyers. Dr. Wood, in hb late woik, aqppears to me to have 
handled this subject bett» than any other of our systematic 
writers. I perfectly agree with him in his conclusions. It ap- 
pears to me that we are better placed than either the French or 
Knglish to study this qnestjcm withoot prejudice, and more Kkely 
to anife at the truth. 

I have placed in the feDowing tabular summary, as a matter of 
::7_-enient reference, the leading points of distinction between 
: T _ IS, and typhnd fcTef, side by side. 

TiiBHs Fktxx. TxPHrs Pxtxh. 

1. MsA ^ Aeea, — Mote ^abeza% 1. Mehs freqaently sodden and jbrmal 



2l BeAvfrnim. 



;._ ;i lace 

lare. Dis- 

liqaad. No 



I 



DIAGNOSIS.— HISTORICAL. 



275 



Typhoid Fever. 

pressure over reiiion of cecum. Meteoric 
tlistention or rigidity of alxlomen. Griping 
pains common, 

5. Emaciation. — IVfore common and 
greater than in t}'-phus. 

6. I^istaxis. — More common tlian in 
typhus. 

7. Hctnorrhagc from the Bowels. — Quite 
common. 

S. CtUancotis Eruptions. — Bright, scan- 
ty, rose-colored eruption; slightly elevated 
above surrounding skin ; readily disap- 
pearing on pressure ; mostly confined to 
skin of chest and abdomen. 

9. Eschars. — ]More common than in 
typhus. 

10. Lesions. — Peyer's glands always 
altered ; generally ulcerated. Mesenteric 
glands reddened, enlarged, and softened. 
Spleen more frequently enlarged and 
softened than in typhus. Ulceration of 
the pharynx and oesophagus more com- 
mon than in typhus. Large intestines 
more frequently distended with gas than 
in typhus. 

1 1 . Causes. — Confined to no geographi- 
cal localities. Prevailing constantly and 
extensively amongst scattered, cleanly, 
M'ell fed, and well sheltered rural popu- 
lations. Occasionally and moderately 
contagious. More frequently sporadic 
than typhus. More generally limited 
to the early and middle period of life 
than tj'phus. 

1 2 . Duration.— Average duration some- 
what greater than typhus. Prolonged to 
the fortieth or fiftieth day much more 
frequently. 

13. Effects of Remedies. — Bearing de- 
pletion better than typhus. 



Ttphus IFevbh. 

gurgling on pressure over region of 
cecum. Meteoric distention very rare. 
Griping pains rare. 
5. 



6. 



7. Very rare. Does it ever occur? 

8. In many cases, especially grave 
ones, more abundant petechial eruption ; 
not disappearing on pressure : — in other 
cases, no eruption. 



9. 



10. Peyer's glands, and mesenteric 
glands healthy. Blood more generally 
dark and gruraous. Dark engorgement 
of vessels and sinuses of brain more con- 
stant tlian in typhoid fever. 



11. Limited to certain geographical 
localities. Generally confined to crowd- 
ed, filthy, and poorly ventilated habita- 
tions. Under such circumstances emi- 
nently contagious. Occurring much 
more frequently after the thirty-fifth 
year of life than typhoid fever. 



12. Terminating fatally, or in recovery 
within the first ten days much more fre- 
quently than typhoid fever. 

13. Requiring more active stimulation 
than typhoid fever. 



I may add here, that while attending to the printing of this 
present edition, I have been seeing every few days at the Penn- 
sylvania Hospital, in Dr. Gerhard's wards, cases both of typhus 
and typhoid fever, — each disease marked by its ownj peculiarities. 
On the 28th of September there was an autopsy of a case of ty- 
phus, in w^hich, as usual, the elliptical plates and the mesenteric 



276 TYPHUS FEVER. 

glands were entirely natural. Tke body was covered with petechise. 
Dr. Gerhard's experience of eleven years, since his study of the 
local epidemic of Philadelphia, in 1S36, has only strengthened 
and confirmed the convictions which he then expressed, of the 
fundamental and specific dissimilarity of the two diseases. He 
has never found any difficulty, that is not incidental to all diag- 
nosis, in distinguishing between the diseases during life ; and this 
diagnosis is always authenticated by the state of the organs found 
after death. 

Amongst the diseases, with which typhus fever may be easily 
confounded, may be mentioned pneumoma tyjpihodes. The two. 
affections have many things in common. In true typhus there is 
often much pneumo-bronchitic congestion, or inflammation. In 
bastard peripneumony there is much of the typhoidal, or conges- 
tive state of the system. It is not possible, however, in the present 
state of our knowledge, to point out with any particularity, or in 
detail, the differential diagnosis of the two diseases. There are 
no full histories of pneumonia typhodes. The accounts of the 
disease, as it prevailed in various parts of the Northern and Mid- 
dle States, between 1812 and 1815, are mere sketches; so loose 
and general as to be of very little value in this respect. The 
more sudden access of the disease; the greater preponderance of 
local, j:horacic symptoms ; the less marked and less early disturb- 
ance of the cerebro-spinal system ; and the absence of the eruption, 
would, in most cases, probably, enable us to distinguish the pneu- 
monia from typhus. 

I may remark here, that it is very important for us to bear in 
mind,ithat great difficulties of diagnosis, in individual cases, are 
in no* way incompatible with the existence of essentially and 
widely different diseases. Morbid affections, very unlike each 
other, and in most cases, easily distinguishable, may, under cer- 
tain circumstances, have many things in common; and their 
symptoms may be so mixed up with each other as to render, in 
the imperfect state of our knowledge, a positive diagnosis very 
difficult, or impossible ; and this without throwing any doubt upon 
the general question of the radical dissimilarity between the dis- 
eases themselves. 



DIAGNOSIS.— HISTORICAL. 277 

The following statement, from Dr. GiJman Kimball, illustrating the influence of 
season upon tlie prex-alence of typhoid fever, was not received in time to be placed 
in its proper position ; and I add it here in the form of a note. There were ad- 
mitted to the Lowell Hospital, during seven years, from May 1S40, to May 1S47, 
six hundred and forty-five patients with typhoid fever. They were distributed 
amongst the twelve months in the following manner, to wit: — May, forty-one; 
June, tliirty; July, forty-seven; August, eighty-six; September, ninety-two; October, 
ninety-eight ; November, sixty ; December, forty-eight ; January, thirty-nine ; Feb- 
ruary, forty-three ; Marcli, forty ; and April, twenty-one. Two hundred and seventy- 
six cases were admitted during tlie months of August, September, and October. 
The number of deatlis was twenty-nine, giving a mortality for the entire period of 
only one in twenty-two and a quarter. The general treatment is negative and 
expectant; many of tlie patients taking nothing but gum Arabic and drinks. 



275 



CHAPTER IX. 



THEORY. 



It is unnecessary to make any general remarks upon this sub- 
ject after what has been said in relation to the theory of typhoid 
fever. A rational interpretation of the phenomena of typhus, of 
their connections, and dependencies, is, if possible, more difficult, 
than in the case of the latter disease. In typhus, there is no con- 
stant and uniform lesion of the solids, to which the symptoms can 
be referred. We certainly have here, if nowhere else in the 
nosologies, a general disease; an essential fever. In regard to 
its theory, and especially to the primary and fundamental disturb- 
ance, which, in its turn, gives rise to the subsequent and con- 
nected morbid phenomena, the sum of which constitutes the dis- 
ease, British medical philosophers are mostly divided into two 
classes; the solidists, and the humoralists. More strictly, w^e 
might call them the neuropathists, and the hemopathists. The 
first maintain, that the impression of the morbid poison is prima- 
rily made upon the nervous system ; the latter maintain, that this 
impression is made upon the blood. I do not propose to enter 
into any history of the reasons urged by the partizans of these 
respective theories in support of their opinions, or in any way to 
discuss their merits. I may be allowed to say, that an undue 
degree of importance seems to me to be attached to them, by their 
authors, and advocates. They are at best only explanations, or 
interpretations, more or less probable, more or less ingenious, more 
or less plausible, of the phenomena of fever, and of the various 
relations of these phenomena. Sydenham's, or Huxham's, or 
Cullen's, may be as good as any of them. They are, probably, 
all of them, more or less erroneous; they may be wholly so.^ Let 

1 There seems to have been in the British medical mind an irresistible tendency 
to philosophize in medicine, and to substitute for the careful observation of facts 
and their rigorous analysis, the doubtful conclusions of speculative reasoning. This 
tendency is clearly enough giving way to a bette? spirit j and there can be no hazard 



THEOkY. 279 

us remember, besides; and a consolatory reflection this is, in the 
midst of these multiform and conflicting tJieories ; that they con- 
stitute an element in medical science of very subordinate, per- 
haps questionable, value. The true science of fever is in its 
appreciable phenomena, and their ascertainable relations; not in 
any explanation of the nature of these phenomena, and these 
relations. 

in preilictingi that the next quarter of a century will witness a complete revolution 
in the temper and philosophy of British medical science. No one can doubt this 
who is familiar with the recent labors of British medical men; and especially with 
tlie tone and spirit of some of their leading reviews. I may refer, without the im- 
putation of invidiousness, for an illustration of what I mean, to an unpretending, 
but most admirable, article in the British and Foreign Medical Review for July, 
1841, on tlie numerical method of investigation; and to more tlian one other paper, 
in the same Review, containing full and frank acknowledgments of the immense 
obligations, which our science owes to the labors, and the example, of Louis; to 
whom, it is no extravagant praise to say, that the spirit of Drydens couplet, so 
far as medicine is concerned, is as applicable, as it was to the great expounder of 
true philosophy : — 

The world to Bacon does not only owe 

Its present kix)wledge, but its future too. 



280 



CHAPTER X. 

TREATMENT. 

I SHALL not enter so fally into the therapeutics of typhus, as I 
have already done in relation to that of typhoid, feyer. It is un- 
necessary to do so, for two reasons ; in the first place, typhus is 
not a disease of very common occurrence amongst us; and, in the 
second place, although there is not, by any means, entire uni- 
formity of opinion, amongst the best and most extensive observers, 
in regard to the most appropriate treatment of this disease, in all 
its details, and under all circumstances ; stiU, there is a good de- 
gree of agreement, in regard to some of the leading points in its 
management. I shall say what seems to be necessary to the 
practical understanding of this subject ; treating, in so many 
sections, of individual remedies, or classes of remedies, and ar- 
ranging them somewhat, at least, in the order of importance, 
which has generally been attached to them. 

Sec. I. — Bleeding. General blood-letting has been pretty com- 
monly resorted to by British practitioners, in the management of 
typhus; although there seems to have been, at all times, some 
practitioners, more than doubtful about the propriety of this re- 
medy. One very striking fact, however, is observable, in connec- 
tion with this subject; and that is the extreme caution with which 
bleeding is, almost without exception, recommended and prac- 
tised. Sangradoism was never popular in the treatment of typhus. 
Amongst the older practitioners, Sydenham, Pringle, and Grant, 
were bleeders; but they were moderate bleeders, as most of their 
successors have been. 

During the early part of the present century, this operation 
seems to have been not often resorted to : and the credit of havinof 
very much aided in restoring it to public confidence has been 
given to Dr. Thomas Mills, of Dublin. Dr. Mills published his 
Essay on the Utility of Blood-letting in Fever, in 1813. But 



TREATMENT.— BLEEDING. 281 

even Dr. Mills, the restorer and champion of the practice, as he 
seems to have been regarded, was what would now be considered 
a very small bleeder. His most common practice was to abstract 
from four to six ounces, and, in many cases, this was not even 
repeated. 

Gilbert Blane, who saw a great deal of the disease on ship- 
board, says of blood-letting, that it is a remedy very ill adapted 
to this sort of fever, particularly in a hot climate.^ 

Sir John Pringle says, — "The pulse is little affected by bleed- 
ing once, if a moderate quantity of blood be taken away; but if 
the evacuation is large, and especially if repeated, to answer a 
false indication of inflammation, the pulse, increasing in fre- 
quency, is apt to sink in force, and often irrecoverably, whilst the 
patient becomes delirious."^ " Many recovered without bleed- 
ing," — he adds, — " but few who lost much blood." 

Dr. Edward Percival recommends bleeding where there is pneur 
monic complication, to the extent of from eight to fourteen ounces ; 
and says, that sometimes, though rarely, it may be repeated once 
or twice. He cautions his readers against large bleedings; and 
says, that patients will sink under them. Dr. O'Brien bled early, 
to the extent of from six to eight ounces, and repeated the pro- 
cess, if necessary, once or twice. Dr. Grattan, and this only 
when the lungs were affected, adopted the same cautious practice. 
In one hundred and sixteen patients, w^hom he bled at the Cork 
Street Hospital, in 1818, the average quantity of blood taken from 
each was only five and a half ounces. Dr. John Cheyne, of Dub- 
lin, had the reputation of being a free bleeder; but he, also, was 
cautious. He says, that he has known the operation to destroy 
life; and that there are many cases of the disease, in which, during 
all their stages, it is wholly inadmissible. His average quantity, 
at a bleeding, was only ten ounces; and he rarely exceeded 
twelve. When more than this amount was to be taken, he con- 
sidered it his duty to be present, and to superintend the operation. 
Dr. Armstrong recommends one or two moderate bleedings, early 
in the fever, and when it is complicated with local inflammation. 
Dr. Southwood Smith is one of the most liberal bleeders amongst 
recent British writers on typhus. But his practice is founded on 
an assumption doubly gratuitous ; first, that inflammation is, in 

' Obs. on Dis. of Seamen, p. 363. 
2 Obs. on Dis. of Army, p. 257. 



282 TYPHUS FEVER. 

ail cases, the morbid condition, which is to be removed; and, se- 
condly, that it is the only morbid condition in typhus fever over 
which we have any control. The phraseology of his directions 
for bleeding is, as it always is, clear, distinct, and emphatic ; but 
the ideas contained in his eloquent words are not so manifest, and 
intelligible, as might be wished. He insists upon the necessity of 
bleeding till local pain is, not diminished only, but removed; till 
inflammation is, not merely mitigated, but subdued. The mere 
mitigation of inflammatory action by bleeding, he even thinks is 
more hurtful, than beneficial. Dr. Smith seems to have changed 
his notions about the utility of bleeding. He informed the author, 
in the summer of 1846, that, at the London Fever Hospital, bleed- 
ing had been performed only four times during the then past year, 
and twice by mistake. Dr. William Henderson's admirable ac- 
count of the typhus fever of Edinburgh, in 1838, and 1839, has 
already been frequently referred to. His analysis of the results 
of his treatment is especially valuable. Of ninety-six females, 
admitted into the Infirmary, during a given period of time, thirty- 
six were bled from the arm; and the average quantity taken from 
each patient was twenty ounces. The circumstances which were 
looked upon as indicating the propriety of blood-letting were, that 
the fever should not have been in an advanced stage ; the indi- 
vidual not of a delicate, or previously enfeebled, constitution ; the 
pulse at least firm, whether small, or full ; and either particular 
local suffering, or general pains, restlessness, and flushing. In 
three instances, some of the most important of these indications 
were wanting ; and two of the three were fatal. The average 
duration of the cases, that were bled, and recovered, up to the 
commencement of convalescence, was eleven days and two-thirds ; 
and the mortality was one in eighteen. Fifty-two other female 
patients, also admitted, successively, during a given period, who 
were not bled, gave a mortality of one in ten ; and the average 
duration of these cases, excluding those of a milder character, in 
which no wine was given, was fifteen days and a half.^ In the 
Philadelphia typhus of 1836, blood-letting was rarely practised, 
and did not appear to be well borne. 

The immediate effects of bleeding seem to be much more ob- 
vious, and decided, in typhus, than they are in typhoid, fever. 

' Edin. Med. and Surg. Journal, Oct. 1839. 



TREATMENT.— BLEEDING. 283 

Thus, of one hundred and forty-nine patients, in whom this means 
was resorted to by Dr. Cheyne, in 1816, ninety-four experienced 
immediate relief. In nearly all the cases, treated at Edinburgh, by 
Dr. Henderson, in 1838, and 1839, the operation of blood-letting 
was followed by speedy relief, or removal, of the local pains, and 
frequently by a mitigation in the severity of other symptoms. 

The conclusions to which we come, then, in regard to this im- 
portant practical matter, are these : first, that general blood-letting, 
to a moderate extent, repeated once or twice, if the indications 
call for it, in the early period of the disease, especially in cases 
where the previous health of the patient had been sound, w^here 
the pulse is somewhat hard, and w^here there is severe local 
pain, constitutes a remedy of great and unquestionable value ; that 
it mitigates the severity, shortens the duration, and lessens the 
mortality, of the disease ; secondly, that this remedy is always to 
be used with great caution ; that there is an unknown element in 
the pathology of typhus fever, which renders this caution always 
necessary, and w^hich, under many circumstances, and in many 
cases, renders the remedy w^holly inadmissible. Amongst the 
contra-indicating circumstances, may be mentioned the advanced 
stage of the disease ; previous debility, or ill health, of the patient ; 
a constitution impaired by excesses, and particularly by that of 
dram drinking; the absence of the special indications for blood- 
letting, which have already been enumerated; and, finally, the 
predominance of the congestive, or typhoid state, characterized 
by the extreme prostration of strength, feebleness of the pulse, 
and torpor of the surface, w^hich marks the disease, more or less 
strongly, during certain seasons. It ought to be added here, that 
some of the Irish and Scotch practitioners do not resort to the use 
of blood-letting at all in the treatment of typhus. Amongst these, 
may be mentioned Dr. Mateer, and Dr. Little, both of Belfast. 
They seem to consider the disease as essentially one of debility. 
Dr. Graves, also, thinks, that the proportion of cases, in which 
general blood-letting can be practised, with advantage and safety, 
is small. 

Local blood-letting may be resorted to, with very uniform benefit. 
There is great unanimity of opinion, in regard to the safety, and 
the usefulness, of this remedy. Scarified or dry cups, applied to 
the nucha, or along the spine, between the shoulders, have been 
found of great efficacy in removing, or diminishing, the suffusion 



284 TYPHUS FEVER. 

of the eyes, the injection of the face, the headache, the delirium, 
and other symptoms. They constituted, in nearly all the cases, 
a part of the treatment pursued by Dr. Gerhard, at Philadelphia, 
in 1836. Speaking, generally, of dr}- cups, he says, — "applied 
in considerable numbers, and left upon the nape of the neck, and 
between the shoulders, for twenty minutes, or half an hour, they 
always seemed to me a more powerful remedy in nervous func- 
tional derangement, not attended with inflammation, than scarified 
cups. I have used them largely in the treatment of the apoplectic 
symptoms of malignant intermittent with the best effects, and re- 
sort to them with confidence, as one of our most powerful means 
of controlling disordered nervous action." 

Sec. II. — Purgatives. The use of purgatives in typhus fever 
by British physicians has been almost universal. At one of the 
Dublin Fever Hospitals, under the care of Dr. Cheyne, it was 
formerly one of the standing directions for the nurse, to administer, 
immediately, to a newly received patient, two pills, composed of 
one grain each of calomel, scammony, and aloes ; the pills to be 
followed, in three or four hours, with a purgative mixture. 
Nearly all the Irish writers reckon purgatives second only in im- 
portance to blood-letting, and much more generally applicable 
than this remedy. Some of them rely almost wholly upon them, 
and upon the ordinary hygienic measures, applicable to most 
febrile diseases. They recommend, that mild purgatives, espe- 
cially during the early periods of the disease, should be so admi- 
nistered, and continued, as to procure two or three discharges 
from the bowels daily. A small quantity of calomel usually 
enters into the composition of the purgative, although the action 
of the mercury upon the mouth is not generally considered desir- 
able. From an examination of the opinions of the best modern 
observers, it is quite clear, I think, that active and drastic purging 
is to be avoided. 

Sec. ni. — Affusions, and Ablutions. The agreement of opinion 
and practice in regard to the external use of water, at different 
temperatures, according to circumstances, is hardly less general, 
than it is in relation to the necessity of purgatives. Dr. Percival 
used the cold affusion, especially in the treatment of children ; 
pouring several gallons of cold water, from a bucket, over the 



TREATMENT.— STIMULANTS. 285 

head and body. On account of the inconvenience of this mode, 
and for other reasons, perhaps, the process of ablution, or spong- 
ing-, has generally been preferred. AVhen the skin is uniformly 
hot, and dry, the water may be applied, in this manner, quite 
cold ; but if the temperature is not much elevated, or if there is 
slight, or partial, perspiration, it is safer and better, thai it should 
be tepid. Dr. Gerhard says, that by frequent sponging, he found 
that he could regulate the heat of the surface with great ease, and 
in some degree, also, could moderate the cerebral symptoms. Dr. 
Graves, of Dublin, has found, that the pain in the head, and other 
symptoms of over-excitement in the brain, are often more speedily 
and effectually relieved, by applying fomentations of hot water, 
than they are by the common cold applications. This is in 
accordance with the extensive experience of my friend, and col- 
league. Dr. Dudley, in the similar treatment of many local affec- 
tions of a painful, or inflammatory, nature. 

Sec. IV. — Stimulants and Tonics. The almost uniform expe- 
rience of British observers has sanctioned the use of stimulants, 
in the treatment of this disease; and, amongst the individual 
articles of this character, a very general preference has been 
given to wine. Some of them urge its administration earlier in 
the fever, than others, and in more liberal quantities; but none of 
them, so far as I know, dispense with it altogether. Dr. Stokes, 
of Dublin, said, in 1839, — ''I feel certain, humiliating though the 
confession may be, that the fear of stimulants in fever with which 
I was imbued, was the means of my losing many patients, whose 
lives would have been saved, had I trusted less to the doctrine of 
inflammation, and more to the lessons of experience, given to us 
by men who observed and wrote, before the times of Bichat, and 
Hunter."^ When the cutaneous circulation is languid, and the 
skin not hot, when the pulse is soft, and feeble, and there are great 
exhaustion, and debility, at whatever stage of the disease, there 
can be no doubt as to the necessity of the stimulating, and sup- 
porting, treatment. During some epidemics, w^hen the adynamico- 
congestive element in the pathology of typhus is marked, and 
predominant, this condition of the system will often be present at 
the commencement of the fever, and will require the early use of 

* Dub. Journ. of Med. Sci., March, ] 839. 



286 TYPH0S FEVER. 

stimulants, and tonics. More commonly, however, this state of 
things attends the later period of the disease, coming on, as the 
febrile excitement subsides ; and then it must be met by the same 
remedies, with an activity, and assiduity, commensurate with the 
uro-encv of its svmptoms. Dr. Gerhard, in his account of the 
Philadelphia epidemic of 1836, says : — " It is difficult to conceive 
the extreme prostration, in which our patients were left after a 
severe attack of fever. The skin is usually cool, and the pulse 
weak, and fluttering, but there are still muttering delirium, and 
g-reat feebleness. Under these circumstances, wine, combined 
with quinine, and a nutritious diet, produced an effect which was 
almost magical. " Dr. Stokes thinks, that in addition to the ordi- 
nary indications for the use of wine in typhus, may be placed 
want of energy in the action of the heart, as shown by its dimin- 
ished impulse, and the feebleness or extinction of the first sound. 
He says, that the existence of these phenomena, at an early 
period of the disease, has sometimes led him " to anticipate the 
bad symptoms, and to commence in good time the use of the 
great remedy;" and that "in others, notwithstanding the exist- 
ence of severe visceral irritations, the use of stimulants has been 
adopted with the best success, from the same indication."^ It 
does not appear to be necessary that wine should be given in 
very large quantities. The daily amount, used by Dr. Gerhard, 
varied from four to sixteen ounces ; in most cases from six to 
eight. 

The only other articles, belonging to this class of remedies, of 
which it is necessary to speak particularly, are the preparations 
of cinchona. Dr. Gerhard, in the latter stages of the disease, 
during the Philadelphia epidemic, and under the same circum- 
stances that indicated the necessity for wine, employed the sul- 
phate of quinine, given in solution, to the extent of about twelve 
grains in the twenty-four hours. Speaking of tonics generally, 
he observes, — " they not only exercised a gradual and permanent 
influence upon the appetite, and strength, of the patient, but they 
produced an immediate impression. The improvement was some- 
times so rapid, that it was very obvious from one day to the next." 
Amongst the means for restoring, temporarily at least, the ex- 
hausted and flagging energies of the system, maybe included the 

1 Duh. Joura. Med. Sci., March. 1S39. 



TREATMENT.— MISCELLANEOUS REMEDIES. 287 

external application of dry heat, and the use of sinapisms. Dr. 
Gerhard says of these latter: — "They were of great and un- 
doubted advantage in the stage of prostration, which occurs at 
the decline of the fever, and certainly contributed to save the lives 
of several of our patients. He also found them useful in dimin- 
ishing the stupor, and prostration, during the disease, as well as 
in reanimating the strength of patients who were brought to the 
hospital, exhausted from neglect, and a fatiguing ride from a dis- 
tant part of the town. But if the fever was high, and the heat 
of the skin considerable, sinapisms were vastly less effectual, than 
when the skin was cool, and the patient seemed sinking from mere 
exhaustion." 

Sec. V. — Miscellaneous remedies. It w^ould be an irksome, and 
not very useful task, to enumerate all the articles w^hich have, by 
one observer and another, been recommended, under certain cir- 
cumstances, and for the purpose of answ^ering peculiar indica- 
tions. I will briefly mention some few of these, the efficacy of 
which has been best established. 

Diaphoretics seem to be of considerable service, in allaying the 
intensity of febrile excitement. Dr. Little, of , Belfast, classes 
them amongst his most useful remedies. The most powerful of 
these has already been spoken of; I mean the cool and tepid ab- 
lution of the body. Amongst the most unexceptionable, perhaps, 
of those to be used internally, are the effervescing draughts, and 
the liquid acetate of ammonia. James's powder has been a fa- 
vorite article with some practitioners. 

When bronchitic or pneumonic complications have not been 
removed, by the remedies already spoken of, resort may be had 
to vesication, and to the guarded use, internally, of ipecacuanha, 
and antimonials. In some cases, where the bronchial secretion 
\yas very abundant. Dr. Henderson found great benefit from the 
administration, several times a day, of from half a grain to two 
grains of the acetate of lead, combined with a small quantity of 
Dover's powder, and one or two grains of squill. Dr. Graves, of 
Dublin, has made use of antimony in the treatment of typhus, 
under peculiar circumstances, the credit of which novelty he 
claims as entirely his own.^ In the latter stages of the disease, 

1 Graves's Clinical Lectures, p. 130, et seq. 



I 



288 TYPHUS rzvER. 

■when there are, in addinon to oiiier symptoms, great piosfiafioii of 
strengtii, and extreme nerrons restlessness, and sleeplessness, he 
gives Tartar emetic, in solution with camphor mixliire, and emn- 
bined with laiidanum. Sis grains of the antunonj are given in 
the course of the twenty-four hours. This comhination, under 
these circumstances, he thinks, possesses an almost magical power 
in allavingr the neiTous restlessness, and in procoiing sleep.^ 

In regard xo the utility of emetics, there is some difl^rence of 
opinion. Thev hare been mostly used under two circumstances ; 
first, at the rery commencement of the ferer; and, secondly, 
"when a relapse, or an aggraration of the symptoms, has heen 
threatened, at, or near the beginning of conTalescence, occasioned 
by some indiscretion of diet. Dr. Gerhard thinks, that they were 
useful, at Philadelphia, in 1836, in diminishing the violence of 
the ferer. Dr. Graves speaks veiy highly of their efficacy, and 
very confidently, also, of their power, if administered within the 
first twenty-four hours fix)m the time of seizure, of wholly arresting 
the disease. 

Camphor and opium are amongst the articles, which have been 
extensively used, for the puipose, principally of allaying nervous 
agitation, and restlessness, and inducing quiet, and sleep. As a 
general rule, they seem to be most eflfectual in accomplishing these 
purposes, when the general febrile excitement is not very great, 
and when there are no indications of irritation, or congestion, of 
the brain. I shall conclude these directicms for the treatment d 
typhus, with Dr. Gerhard's remarks upon these two substances. 
"Camphor," he says, "was certainly amongst the most useful 
and powerful of our remedies. We used it largely, in ihe severe 
cases, especially those in which the ataxic nervous symptoms 
were veiy marked ; and we had no reason to repent its employ- 
ment. In general, there was a marked diminution erf some of the 

» Sir Gilbert Blane ays, — -"Sie hiead being peatiecl?T> -r-:-ri ia this sort of 

fevex, iiie patient is extxemelj restless, and deiirioas, e e r ; : nigiit; and flirae 

is a medicine "wideh. has a most pleasng efeet in pro. _: _ : ^ r' ~ - - ~ ^ r~~5rz- 

tacm- This is a eomlanatioii of an opiate Tiridi an anr- : : : , t . : 5 

administra^ in liie ereoing "vri:"r —f"' : : ; - '■ — ^ ^ T ' 

The same excellent ob^rrer ; : — I. 

liiis adTanoed stage of tiie fever : _ _ : ^ „. r i^^^ : ; : ; _ - 

DC^ restlesaQess, tremois. and : : - :t^:;:v.. :l: —- e 

trasted'io, as opiiim. -srMeli here e.'j'i S5 a ; : ; ^ ;: ; - ; -^1 i.: ;.- z^ t 
^aanodieL^ — Ibid^ p. 3S0. 



TREATMENT.— OPIUM. 289 

most prominent and harassing symptoms. We gave the camphor 
in emulsion in doses of five grains, every two hours, and in enema 
in doses of a scruple. The immediate effect was the lessening of 
the subsultus, and tremors, for which it was chiefly administered, 
and sometimes the diminution of delirium. In some cases, we 
possessed a complete control over the subsultus, which was im- 
mediately checked by an injection containing a scruple of cam- 
phor. It would cease for some hours, but afterwards return nearly 
with its former severity. Still it was a useful palliative, and, like 
most remedies of its class, acted as a useful balance-wheel in 
preserving the harmony of the system until the disease had passed 
through its natural course. The camphor frequently acted pow- 
erfully as an anodyne, when sleep had been interrupted by the 
previous disturbance of the nervous system." 

Huxham is high in his praise of camphor. "Its anodyne 
demulcent quality," he says, "makes it vastly serviceable, in 
quieting the Erethism, and bringing on composure of spirits, 
and easy sleep, w^hen opiates fail, nay, augment the tumult and 
hurry." 

"Opium and its preparations," continues Dr. Gerhard, "were 
used by us in a considerable number of cases. Dr. Pennock was 
the most pleased with their effects. When the insomnia had been 
tormenting, and incessant, and the patient was exhausted by agi- 
tation, and nervous restlessness, a small dose of morphia w^ould 
generally calm the agitation, and procure sleep. This advantage 
was so great, that w^e were induced to give opiates in cases which 
were opposed to our ordinary notions of the proper condition of 
the system for their employment. W^e observed no inconvenience 
from them, and found the morphia occasionally of so much benefit, 
that we should class it amongst the decidedly useful remedies. It 
is not a remedy which should be used in large doses ; as patients 
with typhus are certainly more readily affected by its narcotic 
properties, than they are in any other disease. An eighth or a 
sixth of a grain was the usual dose, and was enough to procure 
sleep. Opiates are obviously improper, w^hen there is much dull- 
ness of intellect, attended with great suffusion of the eyes, and 
countenance." Another positive contra-indication to the use of 
opium, first pointed out and insisted upon by Dr. Graves of Dub- 
lin, is to be found, according to this writer, in a contracted state 
of the pupil. When this is present, he thinks opium is always 
19 



1^ 



I 



I 



immioiKS. Beasmmg; from tiie eoecis cf befladomiA in ciccasioii- 
ing Hilafrarifwi of Hie pupil, Br. Giares was kdto siq^aBe, liiat, 
mven in eases of tjj^ns attended wifli contraction of flie pnpil, 
it nd^it leraoTc the unknown cmiditifHi of tlie biain, vpmi wlddL 
die contractian d^ends; and lie sa^s, fliat he lias nsed it icpeat- 
edly, under tliese circumstances, wifli tcsj satia^cfeoiy results.^ 

Tir ^z*:. idien tlie ferer b^ins to decline, ^onldbe somewlmt 

~ ::r : .'rti^Mis, and sn^Kxting;, flian under the same cirennH 

1 Ad tswer. Tlie omtag^ons diaracterc^tlie disease 

51 :.: :ii i" mind, and ereij means taken to prerent a 

: : 1 : ^ r ■ ' • . :i :: is peculiar poiscm. It seems haidlj necessaij 

: : 1 It ~ : : : ::: :~nit impcntance of cleanliness, finee ren- 

1 r "'^iig- Tliere is no disease, in wMch 

--::-- :. the wd&ie and safety erf" the pa- 

Ti7 t: 7 :\y/-- -:^ '-- medical treat- 

n T 1 " i: : _ t iterrupting" its 

7 :: - . spint, in 

.* v.-:v ^^..:_; 1^7 _!:.-.. 7. ." . : "^_.. _. _ , :: _ ;;"!i''i>^rol!, 

in a papa, — Ji::i ::i^; '^-^. ; 7 :/7.- „„ : _ 7\ i: :_:'_:: :i-es- 

tig^tiwis, crL-i;iT.. :: "..7 ■.: 

fiir Ae year. 1 r ^ 7 I 5 I - I 

Blown allow 5 

medical trE3_ 7 sc^ae, ui in aiauitr ^ .5 

duration, £27 '"fil, wTciy sei: 

Hildenbr^ — :eatmentcanc 

benefit in ai^ : _ :eit wilt 

taiyefiwtsc: 7 _7 - Vn 

lational or ^1 : : .:. 

direct or at : : 7 

natural cocji 7. _ :_ i :::_:;:_ rr^ _:. .. 



r/ 






291 



CHAPTER XL 

DEFINITION. 

This disease, in the present state of our knowledge respecting 
it, may be defined in the following terms: — Typhus Fever is an 
acute affection, occurring at all ages of life ; attacking, at least in 
cities, somewhat more frequently, persons who are recent, than those 
who are old, or permanent, residents ; often transmitted directly 
from one individual to another; very much more common in the 
British islands, than anywhere else, although prevailing, at times, 
in other countries, generally in the form of circumscribed epi- 
demics; often connected with the crowding of many persons into 
small, dark, and poorly ventilated apartments, amidst filth, and 
destitution ; frequently sudden, but sometimes gradual in its ac- 
cess ; attended, at its commencement, with chills, usually slight, 
and in many instances repeated; then, with morbid heat of the 
skin, in many cases very intense, and pungent; with increased 
quickness, with softness, and feebleness of the pulse ; with ac- 
celerated respiration ; in many cases, with the physical signs of 
bronchitis, and pulmonary congestion; w^ith pain in the head, 
back, and limbs; dullness, or perversion, of the powers of the mind; 
drowsiness, or stupor; dizziness, deafness, and ringing, or buz- 
zing, in the ears; morbid sensibility of the skin, and muscles, on 
pressure; extreme prostration of muscular strength; spasmodic 
twitchings of certain muscles ; dull and stupid expression of the 
countenance ; fuliginous flush of the face ; suffusion of the eyes ; 
with loss of appetite and with thirst; sometimes with a slightly 
altered tongue, but in grave cases, with a dry, red, brown, or black, 
and fissured state of this organ ; sordes upon the teeth, and gums ; 
occasional nausea, and vomiting; frequently with a constipated, or 
sluggish, state of the bowels; the skin of the body and extremities 
being generally the seat of an abundant eruption, coming out, in 
most cases, between the fourth and seventh day of the disease, 
and declining, at uncertain periods, during the second and third 



¥ 



2^ TYPHUF FETTR. 

we^, consisting of small spots, generaHy ?::z7-:. - :: :-r.;- 
defined, and irregularly shaped, not nnfreqir:.-. ^ ■ - 

confluent, of a dnsty, dingy, red color, not ^e~z^ : _ ; - .7 
smronnding STirface, and disappearing c'—" '.r-ii-riT ;_7 :: :. :" :: 
all, on pressure ; the body of the patier.: :.:. r:i~T ;::r: r:~:-r 
ont a pungent, offensire, and ammoniacai, ©c : : " :.. ; _. r"-_z - ; :i 5 
differ, Tery -widely, in their duration, in their Tnarntij 1:. -t.: 
seTerity, and in their combinations, in different esses ; »e- t : :.. ; 
them being frequently wanting ; bnt eaoogh of them beinr r - ':.. - - 
rally present to characterize the disease ; tiie SBOSt mpii?nFmT oi 
-which are the loss of strength, the stopor, ^le aai^ian i i €f tlae 
eyes, the inHginoTis skin, and the dosk^, cataneoBS, avpStm"; 
which symptoms may either gradually dimiiaidi in seirentj, aaad 
finally disappear, between the seT^ith a»d Hmtif^ day of Hae 
disease ; or may increase in severity, and trrmiwalr in ddifla, be- 
tween the third and twentieth day &om itt^ir access; tk fiahilily 
to a fatal termination being much less, eaifyyilian lale in fife ; tibe 
bodies of patients exhibiting, on examinatiGaii, afier deaHii, : 
stant pathological changes of any of the digaiis; IwcBt, in 
siderable, though rarrin^- propcrtioii of cases, cn gui j gcim cift cf Klie 
vessels of the brai:. . ". " _ laoderate sub-iradmoid senms effusion ; 
engorgement of the posterior pcation ai the fau^; ledness caTtibe 
mucous membrane of the bronciia; 



of the mucons membrane of the slomadi ; tflie 1i3ood beings 

rally of a darij: color, often Said, car gmmoias, die ooagnla -wiaeai 
formed, soft, and non-fibriajwas ; and the bo%, in raanj casses, 
running rapidly into decomposition: — whick diseaEse, thus dbat- 

racterized, and defined, constit: - - " ' ' ijTidiaal afibdtiiMi, 

differing essentially from all ; :_. t . . . reiaKiBd, by many 

analogies, to typhtad ieTer. 



293 



CHAPTER XIL 

BIBLIOGRAPHY. 

For reasons which must be sufficiently obvious, the literature 
of typhus fever is mostly British. I shall enumerate only those 
original treatises, which have fallen in my way, and which I have 
used, more or less freely, in making up the preceding history. 

Observations on the Diseases of the Army, By Sir John Pringle. 
Dr. Rushes edition, Philadelphia, 1810. Pringle was attached 
to the British array, in the low countries, from 1742 to 1745, and 
also in 1747, and 1748. His experience as an army physician 
was mostly confined to this period of his life. The only portion 
of the observations, of which it is proper to speak particularly 
here, is that relating to the jail, or hospital, fever. This is short, 
occupying, together w4th a reply to De Haen, only sixty pages, 
but worth its weight in gold. His general description of the dis- 
ease, in six pages, is capital. His clear and unequivocal recogni- 
tion of the specific and essential difference between the two great 
forms of continued fever, typhus and typhoid, — called by him, 
jail, or hospital, fever, and miliary fever, — has already been re- 
ferred to. 

Medidna JYautica: an Essay on the Diseases of Seamen, etc. 
By TJiomas Trotter, M. D., etc. London, 1803. This is a some- 
what famous book, rambling, desultory, and egotistical ; flaming 
with patriotism, as it ought to be, since its materials were " gleaned 
amidst the laurels of the British navy, and protected by its ban- 
ners ;" sprinkled with his personal difficulties with his subordinates 
and superiors, and sneers at Dr. J. Carmichael Smyth's nitrous 
fumigation, which he calls "a mock-heroic placebo" for destroy- 
ing bad smells, — but withal rather an agreeable and racy book, 
whose leaves one can at least turn over with some pleasure and a 
little profit. Dr. Trotter saw much of true typhus as it originates 
and prevails on ship-board. The origin of typhus on boarc' 
crowded ships seems very analogous to its frequent occurrence in 
Irish cabins. 



2B4t TYPHUS FEVER. 

,i 7 : J^^ :::..:-€, Causey and Treatment of Cofdagioiis 

7 " : f J. Vol. de SSldenbrand. By S. 

l) Cr :. _ r I 1 S- 9 . Hildenbrand had extensiTe 

r : : : 5 :.: f :: :: :. -S fever, during the latter part 
: ^ s:, :_ :_f ri: :::: : -f present centuries, in the 
7^ - ^- :, :_i;S ::::::i:-i: ::-::_; ^; ;fthatperiod. His work 
25 ;: r...:::i:r y:.i s 5 Tiiiatic monograph on that disease. 1:5 
— ^;:: :i:^\: is '_— :- :s :"z: systematic; there is no disease in ihe 
5 r s : zxr i. ?-- i^ : : -s:ant, and uniform in its phenomenaj — 
-;- ::5 5 _::rjs. changes, march, and duration, — as his simple. 
:^— : .5, "On the fourth day," he says, "there is gene- 

: , T :-_ s : ^ „ : ' r ^ : e e of hemonhage fiom the nose ; critical exacer- 
bations taike place exactly at the end of the third, and at the 
c:ii::if-:ez:fnt of the seventh, day; and subsequently at the end 
c; 1- ri. :: :-.nd at the beginning of the fourteenth day," and so 
cz. t-z i: ■ : : r ; iie disease into eight periods. The fever which 
fei; . fi ::s _^ e r^?-tion was probably mostly i^ifpAuf, mingled, 
: : r t: I . - --: - :r or less, with Uffihaid. This celebrated 
TT : : ^; 15 r : it its intere^ but it has less positive 

T. .3 :.- 1 rz- Ic- :o expect before reading it. In allusion 

: e ;:~t:ti: '.li opposing methods of treatment which have 
- - - : : : :• :.i employed in typhus, he quotes the adage, — 

p ethodo fwn omnes inuidantwr, 

.-: I:: Utility of Blood-Ut&ig m Fever, etc. By 

T .V. D. D:.:ilm, 1816. The object of this work is 

I- i: „ ? ''.\r. I:. ]^ Jills not only makes no distinction 

I f : i r -" :: : :. r . z-, : r _ : 5 : : : ever, — continued, periodical, and 

s : . . . — : : . t r t . : . - 5 with fever, various local inflam- 

n :. .5, T ..5 :. l::i. -cii^: iii regard to diagnosis, renders the 

" ~ ; o?id Treatment of the Epidemic 

F-: . - By Henry Clutterbuck, M. D. 

L . IS- ; T - 5 : : ^ 5 :_ :. : r up, in a good degree, by an 

i::. : : : : _. : : " - r . ' . _ : ' s : ':. r : retical views of the p athology of 
It r: :: -t : :: _7 / :: ./5 disease. His work, containing a 
s::.:r_i;-: :: : r;r iz s. s riiblished as eariy as 1807. He 
rer: - s It 7. :.s an innammation of the brain; and so far as there 
f: ::- :^5^ng started the doctrine of the local infiamnm- 

: _: - : : i t : s. it belongs more to Clutterbuck than to Brous- 

sais. Tifit -5 r::i deal of reasoning and criticism in the 



BIBLIOGRAPHY. 295 

book; but it is always courteous and good tempered. The most 
frequent form of fever, in London, during the prevalence of the 
epidemic, was that corresponding to the slow nervous fever of 
Huxham. He doubts whether the prevalence of fever is as directly- 
dependent upon insufficient food, and crowded and close dwellings, 
as is commonly supposed. Dr. Clutterbuck evidently feels, that 
he has done a signal service to medicine by founding the practice 
of blood-letting, in fever, upon what is called a rational indication, 
or a principle ! thus freeing it from the reproach and disgrace of 
being merely an empirical remedy! Alas, for the blindness and 
fatuity of this miserable and false philosophy! Strongly as he 
relies upon blood-letting, he is constantly insisting upon the 
necessity of great caution and discrimination in its use. This 
seems to have been forced upon him by his experience, in spite 
of the pleadings of his theory. The book is vitiated throughout 
by the hypothetical assumption in regard to the nature of fever, 
and it adds little or nothing to our knowledge of the disease. 

An Account of the Rise, Progress, and Decline of the Fever 
lately epidemical in Ireland, etc. By F. Barker and J, Cheyne. 
2 vols. London and Dublin, 1821. This w^ork is a systematic 
and documentary history of the great Irish epidemic of 1817, 1818 
and 1819. It is one of the most substantial and valuable general 
histories of disease that has ever been written, — a proud and 
worthy monument of Irish science, humanity, and skill. It con- 
sists, in great part, of communications, relating to the epidemic, 
made by the leading medical men of all parts of the country. No one 
can read these papers without being forcibly struck with the high 
qualities of the Irish medical mind, — -its sagacity, its clear common 
sense, its accurate observation, and, compared with that of its 
sister island, its^ freedom from the corrupting influences of systems 
and hypotheses. 

An Historic Sketch of the Causes, Progress, Extent and Mortality 
of the Contagious Fever, epidemic in Ireland, during the years 
1817, 1818, and 1819. By William Harty,M.B., Dublin, 1820. 
The objects of this work are sufficiently stated in its title. It is, 
in every way, a worthy companion to the history, by Dr. Barker 
and Dr. Cheyne. It is written with elegance, earnestness, and 
ability; and it constitutes another of the many evidences of the 
signal excellence of the Irish medical mind. Dr. Harty does not 
profess to detail the symptoms and treatment of typhus; but he 



296 TYPHUS FEVER. 

enters very fully into a consideration of its causes. His views 
upon this subject are marked by the soundest judgment and good 
sense. He insists, with entire conclusiveness, upon the action of 
many concurrent causes, in its production ; and he opposes, with 
equal success, the doctrines of systematists and exclusives. Con- 
tagion, war, famine, want of employment, personal and local 
uncleanliness, unventilated and crowded dwellings, are the chief 
amongst these concurrent causes, — acting, in some instances, 
singly, but more generally together. 

A Succinct Account of the Contagious Fever of this Country, 
etc., hy Thomas Bateman, M. D., F. L. S., etc. London, 1818. This 
is another of the many valuable essays growing out of the great 
epidemic of 1817, 1818, and 1819. Dr. Bateman was a good 
observer, in the British sense of that term, and a sound prac- 
titioner. The value of his book is greatly impaired by the absence 
of all distinction between the typhoid and typhus forms of con- 
tinued fever, — both of which, but principally the former, it is very 
evident, were present, at the period of which he writes. He is 
over positive in his conclusion, that epidemic fevers always depend 
upon scanty and poor food. He insists strongly upon the essen- 
tial identity of all forms of continued fever. He speaks particu- 
larly of the connection between troublesome diarrhoea, and pro- 
tracted cases of the disease, — clearly enough cases of typhoid fever. 
In three autopsies, he found ulceration of the small intestines ; 
and asks if they might not have been produced after death, by 
putrefaction, or by the action of the acrid contents of the bowels! 
He insists strongly on the advantages of the cooling and antiphlo- 
gistic treatment, and dislikes antimony and opium. The last 
chapter is upon the subject of contagion. Its principal objects 
are to show that the fever is less contagious than had been gene- 
rally supposed ; that the poison extends only a short distance from 
the sick ; that dilution with fresh air renders it harmless ; and that 
muriatic acid fumigation acts to the same end. 

A Sketch of the History and Cure of Contagious Fever. By 
Robert Jackson, M.D., London, 1819. This work on typhus is 
by the famous author of the treatise on the fevers of the West 
Indies. It is mostly made up of short and very loose accounts of 
typhus fever, as it occurred during the latter part of the last, and 
the early part of the present century, in various portions of the 
British army and navy. It is of small value. 



BIBLIOGRAPHY. 297 

Practical Observations on the Treatment, Pathology, and Pre- 
vention of Typhus Fever. By Edward Percival. Bath, 1819. 
This ^little monograph was written by Dr. Percival after his 
removal from Dublin to Bath. His description of typhus is pretty 
full and pretty good. Some of his conclusions are loose and hasty, 
— those, for instance, in regard to the connection of certain forms 
and modifications of fever with season and weather. He says he 
is an advocate for the humoral rather than the nervous pathology 
of fever. The book is vitiated throughout by a spurious a priori 
philosophy. Dr. Percival concludes with that stereotyped motto 
of medical books, — " opinionum commenta delet dies, naturae 
judicia confirmat." 

A History of the Epidemic Fever which prevailed in Bristol 
during the years 1817, 1818, and 1819, etc. By J. C. Prichard, 
M. D. London, 1820. This is another of the many local histories 
which were written by British practitioners of the last great epi- 
demic. The author's description of the fever is sketchy and 
imperfect. He considers it entirely settled that typhus often 
originates spontaneously — from unknown causes — and also that 
it is frequently communicated, directly, by contagion. He takes 
strong ground for the old doctrine of a pestilential constitution of 
the atmosphere, favoring the prevalence of certain diseases during 
certain periods of time. "For explaining such phenomena," — 
he says, — "it is not sufficient to trace an infected ship to a par- 
ticular spot, or to smell out a bog on a piece of marshy ground 
near some particular town." 

Dr. Prichard's style is excellent, — clear, strong, correct, and 
always to the point. 

De Videntite du Typhus et de la Fievre Typho'ide. Par C. E. 
S. Gaultier de Claubry. Paiis, 1844. 1 vol. pp. 496. The 
Identity of Typhus and of Typhoid Fever. By C. E. S. Gaultier 
de Claubry. 

The French Royal Academy of Medicine proposed, in 1835, as 
the subject of one of its annual prizes, to be awarded in 1837, 
" The analogies and the differences between typhus and typhoid 
fever.''^ Instead of the prize thus offered, two prizes of encourage- 
ment were given by the Academy, the first to the work above 
named, in which the identity of the typhoid fever of modern French 
writers, and the typhus of camps and jails is maintained, and the 
second to M. Montault, for an Essay advocating the opposite doc- 



298 

trine. Botli 

of li. A: :. 

"don :: _-i _ :. 
My oim © 



we: 



regard 



ing m CE 
contirer' 
In n ' : 



called ty: 

exastrr r f 



lesici: 
idenr"' ; 

near'.;' '.-: 
tcmdei-. "vT 
terized I; 
wnEke tL: 



_~ { Corr/oaokfJiLJj. 
Z.:^_- -:giL, in the cwMtje tl 
JTtg in many resDeets from : 
ir^embliiLr . :. : - : ^ t ■ : 

parti CTlLelL.; -1 " - : - -:'---.'-- 

cases, of blacr " _ " : : . 

~i. 7 7 "' \ - 7IZ11C seeniS 10 Ui-t 
i.L \ : IZ.L.LSI it difficult f o" : 
tainlv, it upskb raott Uiae rt :. 



bT Dt. C: 



BIBLIOGRAPHY. 299 

phus. Dr. Christison makes the common mistake of attributing 
to Louis the opinion that the lesion of the intestine in typhoid fever 
is the pathological cause of the disease. The article has little or 
110 value for Americans, for the simple reasons, that typhus fever, 
without lesion of the intestines, is a form of disease rarely met with 
in this country, except amongst emigrants recently arrived from 
Europe ; and that no clear and well-defined difference is recog- 
nized between this and the form of continued fever generally pre- 
valent here. 

The Article in the Cyclopedia of Practical Medicine is by Dr. 
Tweedie. He recognizes no essential difference between typhoid 
fever, and typhus. The paper in the Cyclopedia, on Epidemic 
Gastric Fever, by John Cheyne, is to us much more interesting 
and valuable. The disease described under this name, is very 
clearly true typhoid fever. 

The more or less systematic treatises of Dr. Armstrong, South- 
wood Smith, and Tweedie, have already been sufficiently referred 
to. Many of the most valuable publications upon typhus fever 
are to be found in the British Hospital Reports, in the Transac- 
tions of Medical Societies, and in the pages of Medical Journals. 



PART THIRD. 

THE 

HISTORY, DIAGNOSIS, AND TREATMENT 

OF 

PERIODICAL FEVER. 

INTERMITTENT; BILIOUS REMITTENT; CONGESTIVE. 



PART III. 
PEHIODICAL FEVER. 

INTERMITTENT; BILIOUS REMITTENT; CONGESTIVE. 

CHAPTER I. 

PRELIMINARY MATTERS. 
ARTICLE I. 

INTRODUCTORY. 

Before commencing the formal description of the disease which 
is to constitute the subject of this Third Part of my book, it is 
necessary to say a few words about the names, which I have 
placed at its head. The disease, which I am here to describe, 
exhibits itself under several forms, so considerably different from 
each other, as to have received different appellations. Still, the 
disease, under all its forms, in all its varieties and modifications, 
is a single, individual disease; as clearly so, as typhoid, or typhus 
fever is. It becomes necessary, then, that this disease should 
have its distinctive appellation, — a name by which it may be 
designated and known. I have accordingly adopted the term, — 
not a new one, — Periodical Fever, as more descriptive and appro- 
priate, than any other, and entirely unexceptionable. Periodical 
Fever is the integral, individual, nosological, disease; Intermit- 
tent Fever ; Bilious Remittent Fever ; and Pernicious Intermittent, 
or Congestive Fever, are the three principal ybrms, or varieties, in 
which the disease shows itself. 

I have felt a little embarrassment in deciding upon the best 
and most suitable method of procedure, in describing the dis- 
ease, thus designated and divided. The three leading varieties 
have many elements in common; they are branches springing 



304 PERIODIC i. I FZTER. 

fiom the same root; but n " isi i -g this, thej differ in some 
respects so widely fiom e ::: it: : :: tieyhave often been 
regarded as spedficaDy dis::!:: ::: s ::?-te diseases; and in 
order to get any dear and adeqiiir ra of them, fliey 

must be separately and individual; r 5 : Z: this descrl : - 

tion is ext^Eided, in detail, to their : : t : s^c-t, it v; 1^ 

lead us into a great deal of tedious : : : etidon; 

and it would be Teiy difficolt to c:i. t :-:.-.: :::~ ^^l.lt 

like a complete and satisfactory jl -. Tth : r ': 

carry along tc^ether the descripti:: It t — 

endeaToiing to put into the same r. t ; : : r 

expTessicms. Amidst these difficuL:: 5. 7 ::_-7 5 t 5 

me :: :'iiSj — to give, in the first place, a full and t 

iff.:: : : ?~ e of the Ibrms of periodical fever, compr: : ^ : 
: 1: 5 if; ■ - : r. 2 A the phenomena and relations that are 

ihen to point out only the pecuKaiir: is. 
: 1 :.: : : : . : t reraaining varieties. "Which of ti r : - 7 
r: i: :;:1 : ::_? :: r iical fever, we choose, fiir this : : r 
T : 7 ::_ 75 ::: ::3n, is not alfcc^ether a il^ :7: 

- : : ::/■.' : iiu piobably strike one, at first sL£i:. 

mraBy fall upon inUrndttad fooer, : 

s 11-75" :l_ i "icated oi these fixms, — ^as tli : - 

11 5:17 7. 77. :f *!ie disease, — and, fin- this :7 : ;, 

77 _v: :_ 17 : — ^ :: t:s ^^ exhibit its characteristic 17 s 

71 : 7::.:7 I , however, that this vie" 5 :.: 

7 :?5 will be mudi m::7 ; - 

; ; ::: 1 - — - --^ description, in \'lz z:y. 

"---■--■ - "ariety; filling up and com .7 : r 

-- : ::7, ; f7 7 ■-'rxMiucing tiie limits a:; 17 

^- >-' '-'-'■ I- 1: : - i _s. The principal re^f :l ::: 

— -^3 : : 7 :: :7 . ::: :i:s purpose, consists in :: 7 
-■'"■ ^ ~ - 71:; : 75 :-- -? ^7: :y:m 7: ?f the phenomena im 
:--y'-y^-^ ~i ::. -:.:-: ::/.: -- ::zi: : y.::: .:. :f the entire diseii7. 






have kr is ez;7 7 . reaerai descriptions of me 



PRELIMINARY MATTERS. 305 

disease, as it shows itself in the southern and tropical colonies of 
the British empire, these descriptions are less elaborate and com- 
plete, than those of some of the more recent French and Ameri- 
can physicians. The earlier classic authorities upon this subject 
were the great Italian writers, — Torti, Baglivi, Lancisi, and Ra- 
mazzini. But their descriptions are generally inaccessible here, 
and they are of course but little known ; it should be said further, 
that they are quite deficient in pathological details. I do not 
know that the modern Italians have done anything in this depart- 
ment in any way worthy their illustrious predecessors. Italian 
medicine, like Italian art, Italian science, Italian poetry, and 
Italian character, has fallen from its high estate, and partakes in 
the general lethargy that broods over that beautiful land. 

ARTICLE II. 

NAMES OF THE DISEASE. 

There are not many diseases with so few synonymes as this 
variety of periodical fever, if we except those names that have 
been given to it on account of its geographical relations. Thus, 
in common with the other grave forms of periodical fever, it has 
been called Walcheren fever, Hungarian fever, Jifrican fever, and 
so on; in India it is frequently called jungle or hill fever. It 
should be added, that it has frequently been confounded, espe- 
cially by British writers, with the yellow fever, and designated 
by some of the many names which have been applied to the latter 
disease. Its most common names are these, — Remittent Fever ; 
Bilious Fever ; and Bilious Remittent Fever. 



20 



306 



CHAPTER XL 

SYMPTOMS. 
AETICLE I. 

XQDE OF ACCESS. 

Thz onset of remittent fever is almost always abrupt, formal. 
and well marked. This onset, according to many observers, is 
not usnalLy preceded by any precursory symptoms ; according to 
otKers, it is, if not generally, at least in many instances, nsbered 
in by sncb symptoms. Dr. VVTlTiam Carrie says, tbat the fever 
m^es its attack, after tbe existence, for a day or two, and some- 
times mncb longer, of a disagreeable sense of languor and de- 
bility.^ Dr. Eoling, in bis excellent paper, on the remittent fever 
of Sontbern ATahamaj says, tbat altbougb tbe attack sometimes 
takes place witent any premonitory symptoms wbatever, it is 
most freqaendy preceded, for a day or two, by siigbt beadacbe, 
"want of appetite, bitter taste in tbe moutb in tbe morning, pains 
in tie joints, and a general feeling of discomfort and uneasiness.^ 
Dr. Dunlavy, in a paper on tbe bdious fever as it prevailed in the 
town of Hamilton, and its vicinity, in Obio, during tbe summer 
and autumn of 1824, remarks, tbat in some cases, patients com- 
plained of pain in tbe bead, sickness of tbe stomacb, occasional 
vomiting, and bitter taste, for several days previous to tbe occur- 
rence of a cbill. If examined at tbis time, tbeir tongues were 
fcund more or less furred, witb some frequency of tbe pulse. 
During liie prevalence of tbe disease, be met witb many persons 
baving a furred tongue, wbo were not aware of any indisposition : 
and be adds, tbat tbis symptom foreboded an attack of fever, 
wbicb. very certainly sooner or later occurred, unless prevented 
by a timely use of evacuant medicines.^ Senac says, — ''tbe 

' Ofas. on Causes ami Care of B^iniTting Fevas p. 45. 

2 Am . Jonrru cf Med ScL. April, IS-M. 

3 West :M&d. and Plirs. J.jnnL, voL L p. 142. 



SYMPTOMS.— CHILLS. 307 

access of the chilly fit is usually preceded by various phenomena. 
These are, a general lassitude and heaviness, a sense of anxiety, 
a yawning and stretching, a paleness, and sometimes a disposi- 
tion to sleep. "^ 

ARTICLE II. 

FEBRILE SYMPTOMS. 

Sec. I. — Chills. The formal commencement of the disease is 
nearly always marked by a distinct rigor, or chill. This varies 
in severity and duration, in different cases: sometimes it is slight 
and transient, at others, it is extremely severe, and prolonged for 
two or three hours. Senac says, — "the chilly fit puts on a variety 
of forms ; sometimes, for instance, beginning at the feet, at other 
times, about the scapuLT, and again, in the back, it runs through 
the whole body, in a manner, resembling small streams of water 
poured irregularly in every direction."^ According to Dr. Boling, 
the initiatory chill is generally slight; sometimes it is a well 
marked ague, w^hile at others, it consists merely in a sensation of 
coldness, felt especially when the patient turns in bed, or in any 
way disturbs his covering.^ In some cases, there is only a single 
chill ; in others, the chill is repeated, usually with diminishing 
severity, once, twice, three times, or more, in the course of the 
disease. Dr. Boling says: — "Where the attack is purely remit- 
tent from the beginning, a second well-marked ague hardly ever 
occurs ; though in all cases, w^hether the first exacerbation was 
ushered in by an ague, or merely by slight rigors, a recurrence of 
the latter in a very slight degree frequently precedes the second, 
and third, and occasionally even the fourth, and fifth, exacer- 
bations. Where the fever is of the double tertian type, the first 
and third, perhaps the fifth, exacerbation may be ushered in by 
tolerably distinct agues, while the second and fourth may be pre- 
ceded by but the very slightest sensation of coldness, if any."^ 
Dr. Stewardson says: — " The recurrence of the chill was subject 
to great diversity; either there were none after the first, or they 
recurred at intervals, most commonly of twenty-four or forty-eight 
hours, for the first few days, and then disappeared altogether, or 

* CakUveirs Scnac, p. 24 2 Caldweirs Senac, p. 24. 

3 Am. Joiirn. Med. Sci., April, 1S46. 4 ibid., April, 1S46. 



SOS PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

again reappeared towards the conclusion, or during convalescence; 
or, finally, showed themselves at various intervals throughout the 
whole course of the disease.^ Dr. William Cume says:— "After 

the second paroxysm, and sometimes after the first, the fever is 
seldom preceded by a cold stage."- 

Sec. II. Re-missions, or Type. This disease is so uniformly, 

and so strongly marked by a repetition, or recurrence, of certain 
svmptoms and states of the system, more or less regularly periodi- 
cal, that one of its qualifying terms has been derived from this 
circumstance. At certain periods of the day, there is an augmen- 
tation in the intensity of all or nearly all the symptoms of the 
disease, sometimes preceded, and at other times not preceded, by 
the chill. This increase of the severity of the symptoms con- 
stitutes what is called Xh.e. paroxysm of the fever, or its exacerba- 
tion. Following this period, and between it and the next, there 
is a c^eneral diminution in the activity of the morbid processes and 
their manifestations, constituting what is called the period of 
remission. "When these paroxysms and remissions occur, each 
once in twenty-four hours, the t^-pe of the fever is said to be quo- 
tidian; when they occur once in forty-eight hours, the type is 
called tertian ; when once in seventy-two hours, it is called 
quartan.) and so on. The most common type is the quotidian, or 
more strictly, perhaps, what has been called the double tertian. 
In this form, there are a paroxysm and a remission, during each 
twenty-four hours ; but the paroxysm of one day differs in severity, 
or in some circumstances, from that of the preceding and of the 
following day, and agrees with that of the third day. The parox- 
ysms of the alternate days correspond to each other. Besides 
these, the most common, there are occasionally other varieties of 
t}^e. Sometimes, for instance, in the tertian form, there are three 
paroxysms and three remissions, instead of one or two, during 
each period. This is the semi-tertian of some writers ; it is the 
triple tertian of Cleghorn. The other varieties it is hardly neces- 
sary to enumerate. The term true has been applied to those 
forms of the disease in which the duration of the paroxysm does 
not exceed twelve hours : when this is considerably protracted, 
the fever is called spurious ; and suhintranf, when the paroxysms 
nearly run into each other. 

^ Am, Jc'urn. IMed. Sci. April, 1S42. - Currie on Rem. Fevers, p. 46. 



SYMPTOMS.— TYPE. 309 



It is alleged by most observers, that the commencement of the 
paroxysm occurs much more frequently at certain periods of the 
day, than at others. Dr. William Currie, for instance, says the 
first attack of the fever is usually between eight and eleven o'clock 
in the forenoon.^ Dr. Cleghorn, in his admirable little Treatise 
on the Diseases of Minorca, makes the following remarks upon 
this point, in the history of remittent fevers. *' Some double ter- 
tians begin in this manner : on the evening of Monday, for ex- 
ample, a slight fit comes on, and goes off early next morning; but 
on Tuesday, towards the middle of the day, a more severe parox- 
ysm begins, and continues till night. Then there is an interval 
to Wednesday evening, when a slight fit commences a new period 
of the fever, which proceeds in the same manner as the first. In 
most double tertians, the patient has a fit every day of the dis- 
ease; the severe one commonly appearing at noon on the odd 
days, the slight one towards evening, on the even days."^ Dr. 
James C. Finley, in a paper on the Autumnal Fever of Georgia, 
says, that " the type is uniformly double tertian, the paroxysms 
recurring with the greatest regularity; one paroxysm commencing 
in the morning, and manifesting a disposition to terminate in the 
evening of the same day ; the other commencing on the afternoon 
of the following day, and continuing through the greater part of 
the night." Dr. Finley says, further, that ** there is a very marked 
difference in the character of these two paroxysms ; that which 
commences in the morning, being alwaj^s more violent and dan- 
gerous, than that which comes on in the afternoon of the next 
day."-^ Dr. Doling thinks that the period of attack will depend 
very much upon the time of the patient's exposure to the exciting 
cause, but he says distinctly, that in fevers of the double tertian 
type, the exacerbations will, in a large majority of cases, be found 
to occur alternately in the fore and after part of the day.'^ It has 
often been alleged that the usual period of access varied with the 
different types of the disease, occurring early in the morning, in 
the quotidian type ; betw^een ten o'clock, and noon, in the tertian, 
and between three and five o'clock in the afternoon, in the quar- 
tan. In relation to this subject, M. Maillot has published the fol- 
lowing curious and interesting table. I omit his distribution of 

' Currie on Rem. Fever, p. 45. 2 Cleghorn on Dis. of Minorca, p. 90. 

3 West. Jour. Med. and Phys. Sci., rol. iii. p. 175. 
< Amer. Jour. Med. Sci., April, 184G. 



310 PERIODICAL FEVEH.— BILIOUS HEMITTElfT FORM. 

the cases according to the month in 'vrhich they occmred. It will 
be noticed that in the two principal types, two-thirds of the cases 
have their access between midnight and noon; that the maximum 
hour is ten o'clock, A. M., and the minimum period from nine 
P. M., to midnight. M. Maillot did not find that the period of 
access was in any appreciable degree influenced by the season, or 
the temperature of the weather. 

Table showing the hours of access in periodical fever. 

QUOTIDIAN TYPE. 

From Midnight to Noojl. 

Hour, 12 3 4 5 6 7 8 9 10 11 12 Total 

So. of cases, 12 15 17 IS 31 51 82 118 163 239 137 206 1089 

From Noon to Midnight. 

1 2 3 4 5 6 7 8 9 10 11 12 Total 

70 113 63 55 54 47 19 22 6 21 10 8 493 

TERTIAN TYPE. 

From Midnight to Noon. 
Hour, 12 3 4 5 6 7 8 9 10 11 12 Total 

No. of cases, 12 5 12 30 22 36 68 63 86 87 72 55 550 

From Noon to Midnight. 
12 3 4 5 6 7 € 9 10 11 12 Total 
33 39 23 27 11 11 9 10 « 8 4 3 180 

QUARTAN TYPE. 
From Midnight to Noon. 
Hour, 12 3 4 5 67 6 9 10 11 12 Total 

No. of cases, 2 « « 1 2 « « « '•' *•' 3 5 13 

From Noon to Midnight. 
12 3 4 5 67 S 9 10 11 12 Total 
" 3 4 1 2 1 1 « '• " 1 « 13 

Ko distinction is made in the abore table between the different 
forms of periodical fever, and the double tertian is not recognized 
as a distinct type.^ 

In regard to the relative frequency of the leading types, I find 
the following positive and valuable statement iu the excellent work 
of Maillot. His remarks apply, without discrimination, to the 
three great forms of periodical fever, intermittent, remittent, and 
congestive. At Bona, in Africa, of two thousand three hundred 
and thirty-eight cases, fifteen hundred and eightj-two were quo- 
tidian, seven hundred and thirty we re tertian, and twenty-six were 
quartan in their type ; at Algiers, of seven hundred and seventy- 
six cases, five hundred and ninety-nine were quotidian, one hun- 
dred and seventy-one tertian, and six quartan. In France, accord- 

' Traite des Fievres Intermittentes. Par F. C. Maillot, p. 414. 



SYMPTOMS.— SKIN. 311 

ino- to M. Nepple, of three hundred and eighty-six cases, one 
hundred and ninety-eight were quotidian, one hundred and fifteen 
tertian, and fifty- nine, quartan. Thus, of three thousand five 
hundred and eighty-six cases, two thousand three hundred and 
seventy-nine were quotidian, eleven hundred and sixteen were 
tertian, and ninety-one were quartan in their type. M. Maillot 
makes no distinction between the simple quotidian, and the double 
tertian type.^ 

It would seem that there is sometimes a tendency to a weekly 
revolution in the phenomena of this disease. Dr. Forry says, — 
" That intermittent fever has a tendency to a septenary revolution, 
is a fact that was frequently verified in Florida, under the writer's 
observation ; and that, too, in a manner so unequivocal, that it 
attracted the notice of the common soldier. At these septenary 
periods, either after the seventh, fourteenth, or twenty-first parox- 
ysm, the disease has a disposition to terminate spontaneously."^ 

Sec. III. — State of Surface. The condition of the skin, like most 
of the other symptomatic phenomena of bilious fever, varies very 
much with the several stages and periods of the disease. Cleghorn 
says, that the cold fit is generally followed by an intense heat over 
the whole body, which raises the mercury in the thermometer to the 
103d, or the 104th degree.^ According to Dr. Stewardson, the heat 
of the skin, during the exacerbations, though often great, is not 
often pungent."* Dr. Boling seems to have studied this matter more 
thoroughly and minutely than any other observer, and I accord- 
ingly avail myself of his full description. " In the forming stage 
of the first exacerbation, the extremities generally feel cool or cold 
to another person, though this is not always the case, even when 
the complaints of suffering from cold are loudest on the part of the 
patient. The temperature of the chest and abdomen, even at this 
time, will generally be found somewhat above the healthy stand- 
ard, and that of the head considerably so. Soon, however, the 
general temperature increases, and the whole surface becomes hot, 
and a vivid flush makes its appearance, not only on the face, but 
occasionally over the whole body, in patients at all plethoric, or of 
a sanguine temperament. This continues for a longer or shorter 

* Traite des Fievres Intermittentes. Par F. C. Maillot, p. 9. 

2 Amer. Jour. Med. Sci., Oct. 1841. 

3 Dis. of Minorca, p. 94. 4 Amer. Jour. Med. Sci., April, 1842. 



312 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

period, dependent, in a great measure, on the type the fever is 
about to assume ; for it will be shorter in the paroxysm of a quo- 
tidian, than of a tertian, when the heat and redness of the sur- 
face decline, and a perspiration appears, in the form at first of the 
slightest moisture between the under jaw and neck, gradually 
becoming general and free. In the succeeding paroxysms, the 
heat of the body is still about the same; but if the case be at all 
protracted, there is, after a certain period, a tendency to coolness 
in the extremities, even during the height of the exacerbations ; 
but, unlike the coolness attending the early rigors, the patient is 
unaware of it, and is much distressed with a sensation of burn- 
ing heat. This coolness of the extremities gradually increases 
with each succeeding exacerbation, after it has once appeared, 
and in cases far advanced towards a fatal termination, frequently 
extends nearly to the shoulders and groins, the surface of the ab- 
domen and chest being most intensely hot, at the same time. The 
perspiration attending the remissions becomes less and less in 
each, and in the advanced stages of an aggravated case, is re- 
placed by a clammy exudation from the cold extremities, while 
the body is dry and parched. The vivid flush of the surface is 
much less apparent w^ith ^ach succeeding exacerbation, and in its 
place, a very slight shade of a purple or livid tint makes its ap- 
pearance, — more obvious in the face than elsewhere. Frequently, 
however, the skin becomes yellow; the shade, scarcely percep- 
tible at first, gradually deepening over the whole body, but not 
commencing and proceeding from any particular point, as is said 
to be the case by Lempriere, Bancroft, Mosely, and others, in the 
yellow fever. It is, however, for a very obvious reason, most fre- 
quently first noticed in the conjunctiva. Petechiae and vibices are 
never seen, though sudamina are occasionally observed in pro- 
tracted cases. They generally appear only about the neck and 
breast, and are much more common with children than with 
adults."^ It should be mentioned that Dr. Boling's remarks have 
reference especially to the severer forms of the disease. 

Sec. IV. — Heart and Pulse. The pulse is more or less accele- 
rated during the febrile paroxysms, rising frequently to 120 or 130 
in the minute, and falling nearly to its natural standard in the 

* Amer. Jour. Med. Sci., April 1846. 



SYMPTOMS.— HEADACHE. 313 

intervals. Of eleven cases treated by Dr. Gerhard, at the Penn- 
sylvania Hospital, in 1834, and all terminating in recovery, the 
pulse was over 100 in only two. It is very rarely that it has the 
hard tense feel of the open inflammatory pulse. Sometimes it is 
moderately hard and strong, or jerky; but more commonly it is 
rather soft and feeble. Towards the close of fatal cases, the 
pulse usually becomes excessively rapid, "becoming smaller and 
thready, and at length imperceptible."^ Dr. Boling remarks, that 
the action of the heart is laboring and strong, its sounds louder 
than natural, and its impulse more forcible. 

ARTICLE III. 

THORACIC SYMPTOMS. 

Very few writers upon remittent fever make any formal mention 
of symptoms connected with the respiratory organs ; and it seems 
quite certain that thoracic complications are rare and accidental. 
Bronchitis, sometimes with mucous rattle, but oftener without it, 
occurred in twelve of Dr. Swett's thirty-four cases; and he thinks 
that pneumonia was the immediate cause of death in two instances. 
Dr. Stewardson speaks of the general infrequency of this class of 
symptoms; and Dr. Boling merely mentions the moderate accele- 
ration of the breathing usually accompanying febrile excitement. 

ARTICLE IV. 

CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. 

Sec. I. — Headache: — Pains in the Back and Limbs. Pain in 
the head, back, and limbs, is one of the most constant, and in 
many cases one of the most distressing accompaniments of this 
disease. Cleghorn says, he has sometimes known this pain so 
intolerable, and accompanied with such inexpressible anxiety, 
that persons of the soundest judgment and morality have been 
tempted to destroy themselves to get rid of it.^ Dr.- Stewardson 
found headache present in all but one of sixteen cases, terminating 

^ Dr. Swett, in his account of thirty-four cases, treated at the New York Hospital, 
in 1844, says, that during the paroxysm the pulse usually ranged from 106 to 112, 
falling in the intervals to 96 or 100. 

2 Dis. of Minorca, p. 132. 



! 



314 PERIODICAL FE^'ZK —BILIOUS REMITTKNT FORM. 

in recoTerT. It generally commenced on the first day of the 
fever, was most serere during the exaceibatioiis, and oomnicmlj 
declined after the raiddle period of the disease, at least during 
those honrs of the i;;- '--■:.-" the patients were Tisited-* Dr. Boliiir 
gives the following :- : : : .-: of this symptom as it ^lows itself ::: 
severe cases. "As the febrile excitement is deTeloped in the jSjs: 
exacerbation, pain in the head becomes Tiolent and distressirr- 
and is of a throbbing character. It is geneiaify in the fixelieEi . 
just above the frontal simises, but is also occasionaiDj felt in in 
occipital region. During the eaiiier remissions, it eifber abaTfs 
or entirel}- subsides, but later, is Teiy distressing during the remis- 
sions. At this period. :: -3ses its throbbing, pnlsadngcti- 
racter, and is fixed ani 5: r i ;' ; . ' '^ 

S:ec. n. — Mind. I) r ; : . t . 7 /. . ; . :i : f :. : : 1 : : :_ :i : :. ; 7 niptom, 
at least in mild cases, an^. 111 inose 01 n : -7 :'7 17" 7. : T^.ere 

was slight deliriuni in only one case c : 7 _ 7 7 :, . :-: . _ : :: 

recovery, at the Pennsylvania Hospitc'. ::. 1^:^ _: : 77L 
cases, also terminating &LVonibly, :r. ''1 7 5 : :_ 7 : . r " . :: - 

served by Dr. Stewardson, detirinm '^ : ^ : 7 . Ii 

one, it was slight ; in the other, 110I7:::, ::. „ ; ; \::. 7 , 

the exacerbations. Of J>r. Swett's mirij-ic.-. ; :7:. :.-7 -'7" 
York Hospital, there was delirium in fiTe. I I r 5 
of this symptom, as of many of the odiers, is ji 1 

minute. It is imr : r' :. - ' t :• remember, that he .5 ; _ 7 : . 1: . . _ ... 
grave cases, altho .: _ i. ■ ^ :.ys of the simple 2_r. 1 :: : : "':. r ::i :. . : r :. : :. : 
or congestive forni :::i7 disease- **WLr:7 "7 iz\:\.~ -'::\: z. :..-:..'. 
mns high," — he sajs. — •■ f'ir^* ^7~t-7i:' .-:.:_i::. :;; :" 7"r:: 
during the first exacc:. ;.:.::.., I: :5 -;i;5: ::7::7:.:/ : ;:Ti 

with a drowsy stupor, during the pi: . i ; ^: .r :: :- :" :5 

manifested, and passes away as sooi: :5 :..7 ::. 7:.: £::t:. .7 :."/•• 
roused, to bestow his attention. This ' 7 '_ : : . : :i . /. 1: 7 - i . . : ■ " ; 1 ^ _ 
in the first exacerbation, may be pre; 7 

severity, and under the use of a geni. 7 ; : ' : 1 . i 7 7 . : 

OT the spontaneous evacuation of ti.7 r ; ; _ : 

return again in the succeeding exc 7 : : / /_ :. :_ : 

lence of the disease may not be subu ur 1 _ . : -- .. 7 7 _ . : : :- ^ 
in which the symptoms generally are on : :. 7 : :. : : 7 1 5 7 is : 7 r :. : 

* A-mer. Icmxn. 3Ied. Sd„ April, 1^13. ^ !.„.. ^_:-_. '.i-.'.. 



SYMPTOMS.— SENSES. 315 

severity, it may remain absent during several exacerbations, and 
then again appear, or may not return again at all should the 
patient recover ; or should he die, but in the last exacerbation. 
With the exception of this temporary delirium just spoken of, a 
patient is apt to pass through several exacerbations without any 
intellectual aberration. It generally occurs earlier in sanguine, 
plethoric subjects, and in such is less indicative of danger. Once 
fairly established, with the exceptions above noted, like all the 
other phenomena of the disease, while the other symptoms are on 
the increase, this one is also progressive, and becomes worse and 
worse with every exacerbation. During the remissions, at least 
the earlier ones, the delirium disappears, and even in the later 
ones, generally abates considerably in violence, though but shortly 
before a fatal termination. An amendment once commenced, in 
a case where the delirium disappears during the remission, this 
symptom scarcely ever returns, however slow the progress of the 
cure; but where the delirium remains during the remission, it 
may continue even after a decided amendment has taken place, 
abating more or less every day till its complete disappearance, 
which always takes place during the hour of remission. The 
delirium is scarcely ever so violent, except in a few malignant 
cases that run through their course very rapidly, as to require any 
restraint of the patient. In a very few protracted cases only, does 
it assume that character called low and muttering, and is seldom 
if ever attended with picking the bedclothes, or subsultus ten- 
dinum, though occasionally the hands are extended in sleep, as if 
reaching for some imaginary subject of a troubled dream. "^ Som- 
nolence, dullness, or stupor, is an occasional but not very con- 
stant or striking symptom. 

Sec. III. Senses, and Physiognomy. — Dizziness, and ringing 
in the ears are present in a certain number of cases, but they are 
far from being common. Deafness is hardly ever noticed. Dr. 
Boling says, — "The expression of the eye has nothing peculiar 
in it in the earlier exacerbations. Where the febrile excitement 
runs high, it is, perhaps, bright and sparkling, the conjunctiva 
retaining its pearly whiteness, and this sometimes continues to 
the last paroxysm; the patient's countenance wearing now an 

* Amer. Journ. Med. Sci., April, 1846. 



316 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

expression of indescribable anxiety. At other times it is suffused, 
and of a reddish muddy tinge ; its motions are slow and languid ; 
and, in such instances, the countenance wears rather an expres- 
sion of dull indifference."^ 

Sec. IV. — Muscular Strength. Prostration of muscular 
strength, and a sense of debility, are early and almost invariable 
attendants of remittent fever. But, according to Dr. Boling, this 
extreme degree of feebleness is sometimes more apparent than 
real. He says, — "The sensation of debility is extreme, and is 
frequently as much complained of in the first or second exacer- 
bations, as later in the disease, when the actual debility is much 
greater. At a time when a patient will make complaints of the 
greatest debility, let it become necessary for him to get up, or 
assist himself in any way, and he will do so without any call for 
aid ; or if he does demand it, will show himself at the same time 
capable of considerable muscular exertion. It is only in very 
protracted cases — and few such occur in this part of the country 
— that the patient requires much assistance in performing any 
necessary movements, provided he is sufficiently sensible to be 
aware of what is necessary."^ Twitching of the tendons, and 
hiccup, are present in a small proportion of cases. 

ARTICLE V. 



Sec. I. — Tongue and Mouth. The tongue is generally more 
or less thickly covered with a yellowish, or dirty white fur, — the 
color being probably occasioned, in many cases, by the fluids 
ejected from the stomach. The edges of the tongue are often 
somewhat redder than natural. During the early periods of the dis- 
ease, the tongue usually retains its moisture ; but, in grave cases, 
especially, and after the third or fourth paroxysm, it frequently 
becomes parched and dry, dark brown, or nearly black, on the 
dorsum, more intensely red on its edges, and sharpened at its 
point. Dr. Swett found the tongue usually coated, first with a 
thin white, and at length with a more thick and dirty coat, but 

I Amer. Jour. Med. Sci., April, 1S46. 2 ibid., April, 184'3. 



SYMPTOMS.— APPETITE AND THIRST. 317 

remaining moist to the end of the disease, in at least two-thirds 
of the cases ; it was noted as becoming dry in only twelve of 
thirty-four cases. ^ These and other morbid states of the organ 
are much more strongly marked during the paroxysms than in 
the intervals, at which time the tongue often returns nearly 
to its natural condition. In eleven of Dr. Stewardson's cases 
which recovered, where this point was noticed, the tongue began 
to clean on or before the twelfth day in eight, and from the thir- 
teenth to the twentieth in the remaining three. 

There is more or less dryness of the mouth during the febrile 
paroxysms. "Late in the disease," says Dr. Boling, "when the 
case is of so aggravated a character that a few shades further put 
it beyond hope, the whole interior of the mouth becomes, as it 
were, almost completely dry, and the mucus inspissated, dry, and 
black, is collected on the lips and between the teeth. The patient, 
during the first two or three paroxysms, frequently complains of a 
bitter taste in the mouth; but after this, with the exception of the 
impression made by matters vomited up, and the taste left by 
medicine, nothing peculiar in this respect is observed, till the 
commencement of convalescence, when a disagreeable bitter taste 
is again complained of for a few days."^ Dr. Stewardson says, 
sordes about the teeth either did not exist, or were so slight as 
not to be noticed. 

Sec. II. — Appetite and Thirst. The testimony of observers is 
very uniform in regard to the entire absence of appetite for food. 
Dr. Boling says, — " From the commencement of the attack, 
during nearly the w^hole period of the disease, the disgust for 
food is almost insurmountable. It is only during one or two of 
the earlier and more complete remissions, that a patient can be 
induced to swallow any kind of nourishment, and that only at 
the solicitation of friends, and not from any desire of his own. 
Towards the close of a case that is taking a favorable turn, and 
before the establishment of complete convalescence, he will swal- 
low a few spoonfuls of light broth, or something of that character; 
and even then not to gratify any desire of his appetite, but from 
a persuasion, that nourishment is necessary for him in his w^eak 

I Am. Jour. Med. Sci., Jan. 1835. 2 ibid., April, 1846. 



318 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

state. When convalescence is completely established, the appe- 
tite is generally craving, and the strength is rapidly restored. In 
the case of negroes the disgust for food is a much less prominent 
symptom.^ 

The thirst, the desire being for cold drinks, is most excessive from 
the very first paroxysm, and this is almost the only symptom of 
the disease which does not increase with the repeating exacerba- 
tions, so long as the disease may be considered unchecked. But 
although the thirst, in the first exacerbation, is, as a general rule, 
so great as to leave no room for it to increase, it is not so with the 
remissions. During the first remission, the thirst abates some- 
what, but this abatement is less and less with each one that suc- 
ceeds, and after a while, even during the period of remission, the 
thirst is most excessive, and large draughts will be rapidly and 
in quick succession swallowed, although with the confirmed as- 
surance that in a few minutes they must be returned. Pure cold 
water is the drink most generally preferred, and if any addition 
is at all desired, it is always something sour, such as vinegar, 
tartaric acid, or lemon-juice.^ Dr. Baldwin, in his account of the 
bilious remittent fever which prevailed in Burke County, Georgia, 
in 1831, says, that a bitter taste in the mouth, and an intolerable 
thirst w^ere universally present.^ Bailly says, — "One must be 
sick at Rome in order to know the happiness of drinking cold 
water. "^ 

Sec. III. — JYausea and Vomiting. These symptoms are amongst 
the most constant phenomena of the disease. Vomiting very often 
accompanies the first rigor; and, in most cases, is more or less 
frequently repeated, especially in the paroxysms, during the whole 
course of the disease. The fluids ejected from the stomach are 
usually of a greenish or yellowish tinge, varying in shade and in- 
tensity, in different cases. Dr. Boling says, that in grave cases, 
and in the advanced periods of the disease, although the efforts to 
vomit become more incessant, the matter vomited diminishes in 
quantity, so that, frequently, in hours of straining and retching, 

1 This peculiarity in the case of negroes was noticed by Dr. Gerhard in the 
epidemic typhus of Philadelphia, in 1836, and has already been spoken of in this 
work. 

2 Amer. Jour. Med. Sci., April, 1846. a Ibid., Feb. 1832. 
4 Traite des Fievres Inter mittentes, p. 137, 



SYMPTOMS.— EPIGASTRIUM.— ABDOMEN.— BOWELS. 319 

nothing is thrown up but the drinks which had recently been swal- 
lowed. 

Sec. IV. — Epigastrium and Abdomen, Another symptom be- 
longing to this strongly marked group, and almost invariably pre- 
sent, is pain or tenderness of the epigastrium, increased by pres- 
sure. There is also some degree of fullness, or a sense of fullness, 
weight, tension, and oppression, extending across the hypochon- 
dria, especially on the left side, in the region of the spleen. This 
feeling is often quite distressing, and adds much to the discomfort 
of the patient. The epigastric uneasiness and oppression are often 
relieved, temporarily at least, according to Dr. Boling, by the act 
of vomiting. True tympanitic distention of the abdomen is of 
rare occurrence.^ Enlargement of the spleen is rendered manifest 
by the increased and extended dullness on percussion over the 
region of this organ. 

Sec. V. — Bowels. The bowels are, to say the least, generally 
free from any considerable degree of irritation, so far as this is 
indicated by pain or diarrhoea. Of Dr. Gerhard's cases at the 
Pennsylvania hospital, there was diarrhoea in only one in seven. 
Dr. Stewardson, in his account of seventeen cases, which were 
treated at the same institution, in 1838, all terminating in reco- 
very, says, — " The bowels were generally costive, the purgative 
medicines which were given both before and after admission rarely 
occasioning hypercatharsis. In a few instances, spontaneous 

* Dr. Boling has an observation somewhat opposed to the statement, which I have 
considered myself justified in making, in relation to this symptom. " Sometimes," — he 
says, — " in cases of a very violent character, this tympanitic distention supervenes 
early in the disease under the action of a few small doses of purgative medicine, 
and accompanies almost alvjays a spontaneous diarrhcea, tvhich, in a few cases, makes its 
appearance early.'''' In the absence of any distinct and conclusive information upon 
this point, one can hardly avoid the suspicion, that the cases thus marked by tympa- 
nites and spontaneous diarrhcPM, were cases of typhoid fever. A previous remark by 
Dr. Boling justifies, I think, the suspicion which I have ventured to suggest. Towards 
the close of protracted cases, he says, there is sometimes an obscure sensation of pain 
between the umbilicus and the right iliac fossa. At any rate, and be this' as it may, 
the general absence of this symptom is expressly admitted, by Dr. Boling, as well 
as by other observers. Dr. G-erhard Ibund it in only two of eleven cases at the Penn- 
sylvania Hospital. Dr. Stewardson says, in the history of his cases, that flatulent 
distention, except in a slight degree, was not noticed in a single instance j. and Dr. 
Swett says, that tympanites, even in the cases where prostration was most marked, 
seldom or never existed. 



I 



320 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

purging was present near the commencement of the disease, and 
continued for a few days ; but subsequently the bowels were either 
regular or costive, unless when operated on by medicine."^ Dr. 
Swett remarks, that diarrhcea was absent in almost every case ; 
that all his patients required purgatives at some period of the dis- 
ease, and that they usually acted freely without leaving any symp- 
toms of irritation behind them. Dr. Boling thinks that this dispo- 
sition to sluggishness in the bowels has been over-stated, and that 
although spontaneous purging may be rare, there is still a strong 
tendency to diarrhoea, — a tendency rendering great caution neces- 
sary in the use of cathartics, especially after the first or second 
exacerbation. It is very probable, that the irritability of the 
bowels may be greater during certain periods, and in certain 
locaHties, than in others : and it is very important, furthermore, 
to remember, that Dr. Boling expressly excludes from his descrip- 
tion, the entire class of mild or moderate cases. 

The character of the discharges from the bowels seems to vary 
very considerably in different seasons, and in different localities; 
and not unfrequently, also, during the different periods or stages 
of the disease. The more general, and, to a certain extent, cha- 
racteristic, appearance of the stools, is that which has been deno- 
minated bilious. These stools vary in color, from different shades 
of yellow and green, to olive, brown, and almost black. Some- 
times this bilious quality of the discharges is entirely wanting. In 
the fever of 1831, in Dallas County, Alabama, Dr. Heustis found, 
early in the season, the discharges from the bowels mostly of a 
light clay-colored complexion, with very little of the black, green, 
or bilious discoloration, so generally present. In a few cases that 
occurred after the commencement of cool weather, the stools were 
highly colored, of a dark green, olive, and almost black ; becoming, 
in the progress of the complaint, of a lighter hue, between an olive 
and a brown, and of a gelatinous, sleek, and oily appearance, but 
not peculiarly offensive.^ Dr. Swett says, — " In many, the secre- 
tion of bile, as marked by the stools, was much increased in quan- 
tity, or altered in its color, so as to constitute one of the most 
striking symptoms of the disease. This was observed in fifteen 
or about one-half the cases ; while it was also noticed in many, 
even of the worst cases, especially among those which were admit- 

' Amer. Journ. Med. ScL April. 1S42. 2 Ibid., Feb. 1532. 



SYMPTOMS.— URINE. 321 

ted early in the seasoji, that 7W apparent deviation from the healthy 
standard took place ^^ Lumbrici frequently accompany the dis- 
charges, especially amongst negroes and children. ^ 

Sec. VI. — Urine. Observers are not agreed amongst them- 
selves in regard to the state of the urine. Cleghorn says, — " The 
urine, Avhether made in the time of the paroxysm or interval, is 
always clear, frothy, and of a deep red color, without any sepa- 
ration."^ Senac lays great stress on the appearance of the urine, 
as characteristic of periodical fever. "Masked intermittents," — 
he says, — " may be no less certainly detected, as was formerly 
observed, by the color of the urine. In that disease the urine is 
very often lateritious, during the remission, which is a sign, almost 
infallible, that the disease belongs to this family."^ According to 
Dr. William Currie, the urine during the cold stage is pale, copious, 
and crude ; but as soon as the hot stage is established, and during 
its height, it becomes high colored ; while, in the remission it is 
thick and cloudy, and sometimes deposits a brick-colored or 
brownish mucous sediment.^ Dr. Stewardson says, — "• The urine, 
where noted, was mostly clear, sometimes straw-colored, at others 
highly colored, reddish, or of a more or less deep yellow, approach- 
ing to orange."^ Dr. Swett found the urine generally natural in 
appearance, and without sediment throughout the disease.'^ Dr. 
Boling, on the other hand, says, — " The secretion of urine is 
scant and highly colored, and muddy, during the exacerbation, 
from the coloring matter floating suspended in it ; and sometimes 
late in the disease, is of a de'ep reddish-brown, possessing ap- 
parently a degree of consistency greater than natural, and is 
passed with pain. In the remissions, it is more copious and trans- 
parent, but throws down a muddy flocculent deposit sometimes, 
at others a red, pulverulent, matter."^ 

' Am. Journ. of 3Ied. Sci., Jan., 1S35. 2 Boling on Rem. Fever. 

3 Dis. of Alinorca, p. 133. 4 Caldwell's Senac, p. 122. 

5 Currie on Bil. Fev., p. 46. 6 Amer. Jour. Med. Sci., April, 1842. 

' Ibid., Jan., 1845. 8 Ibid., April, 1846. 



21 



322 



CHAPTER III. 

ANATOMICAL LESIONS. 
ARTICLE I. 

LESIONS OF THE THORACIC ORGANS. 

Sec. I. — Lungs. The substance of the hings, and the mucous 
lining of the air tubes, are the seat of no constant or important 
lesion. Congestion of the former, especially in their posterior 
portions, and more or less redness of the latter, are found in a 
certain proportion of instances. Two of Dr. Swett's cases were 
complicated with pneumonia. Baillj mentions the lungs in only 
a part of his cases, and in nearly every instance where he does 
so, calls them healthy. Maillot found the lungs as free from dis- 
ease as after death from any acute affection. 

Sec. IL — Heart; Blood. The muscular tissue of the heart is 
frequently softened and flabby. Dr. Stewardson found this organ 
flabby in three of the six cases, in which it was particularly ex- 
amined ; and combined with this flabbiness there was diminished 
consistence at least in two cases. In nine of Anderson and 
Frick's twelve cases, the heart was examined, and in all of them, 
its muscular tissue was found to be more or less softened. Mail- 
lot found the heart in six cases pale and softened ; once, of a yel- 
lowish color and flabby ; once, flabby, with dilatation of the left 
ventricle; and in four cases with hypertrophy of the walls of the 
left ventricle.' In another place, Maillot calls the paleness and 
flabbiness of the heart, mentioned above, '■'truly remarkable. "^^^ 
Dr. Swett does not seem to have noticed particularly this altera- 
tion. In the three cases of Dr. Stewardson, where the heart was 
softened, its inner membrane was of a reddish brown, deep red, 
or violet color; in Anderson and Frick's cases, this membrane is 

1 Traite des Fievres Intermittentes, p. 286. 2 ibid., p. 291. 



LESIONS.— BRAIN. 323 

generally described as pale. In regard to the nature of the fore- 
going lesions, I can only repeat \vliat has already been said upon 
the same subject in connection with typhoid and typhus fever. 

The state of the blood in remittent fever has not yet been made 
the subject of sufficiently extensive or accurate study to justify 
us in saying anything very positive about it. Dr. Swett does not 
notice the blood at all, except to say that, in one case, examined 
in the heart, it was fluid. Bailly takes no special notice of it. 
Dr. Stewardson examined the blood contained in the cavities of 
the heart in five cases: in one, there were black coagula, mixed 
with red serum; in the others, fibrinous coagula, soft in two; 
semi-transparent and greenish, in another, and generally small. 
No large, firm, fibrinous coagulum was found in a single instance.^ 
The state of the blood in the heart is mentioned in only one of 
Anderson and Frick's cases; in this, there were large fibrinous 
concretions. 

ARTICLE II. 

LESIONS OF THE CEREBRO-SPINAL APPARATUS. 

Sec. I. — Brain, and its Envelopes. I do not think that the con- 
dition of the brain and its membranes, after death from remittent 
fever, has yet been satisfactorily determined. It was examined 
by Dr. Stewardson in five cases. "The sub-arachnoid effusion 
was either entirely wanting or moderate, except in one case, where 
there was a considerable quantity of reddish serum. In the same 
case, the ventricles contained an ounce of bloody serum, whilst 
in two of the others, they were empty, in a third, nearly so, and 
in the fourth, contained scarcely a drachm of fluid. In one, the 
walls of the ventricles were of a yellow color. The pia mater 
w^as deeply injected in one case, in which also there appeared to 
be a slight effusion of blood into the cells in a small circumscribed 
space ; its veins much distended posteriorly in another. The 
cortical substance was of a deep shade in two cases, and in none 
is it mentioned as being paler than natural, or presenting other 
alteration. In two cases, the medullary substance was natural; 
in a third, it felt pasty without giving the sensation of softness ; 
whilst in a fourth, it was soft and pasty, being at the same time 

' Araer. Jour. Med. Sci., April, 1841. 



324 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

dry and of a milk white color, with few bloody points. In a fifth, 
its color was a dirty white, mixed with a faint reddish brown, — 
its consistence natural, with the exception of a slight central soft- 
ening."^ Dr. Swett describes the substance of the brain as 
natural, in four of his five cases; in the other, the central portion 
of the left side was somewhat softened. In two cases, there was 
slight sub-arachnoid eflfusion. Neither Dr. Stewardson nor Dr. 
Swett seems disposed to regard these cerebral lesions as in any 
degree important, or peculiar to this disease ; — they look upon 
them as wholly accidental, or at least such as occur with the same 
frequency and to the same extent in other acute febrile affections. 
This conclusion may prove to be sound ; but I do not think, that 
we are justified in adopting it, without more extensive researches. 
In ten of the twelve cases, reported by Anderson and Frick, the 
brain and its membranes were examined, and in all of them, 
there was more or less alteration. In eight, the substance of the 
brain was more or less injected ; in two, it was natural. In two 
cases, the pia mater was healthy; in the others, it was injected, 
or its meshes infiltrated with serum, or both ; in one case, there were 
three ounces of serum between the arachnoid and dura mater. ^ In 
their connection with this subject, I have examined and analyzed 
with some care the cases reported by Bailly. They occurred at 
Rome, during the summer of 1822. It is important to remark, 
that they all belonged to the variety of pernicious intermittent Sy 
as they are called, in other words, they were cases of congestive 
fever, as were also many of those the lesions of which have al- 
ready been described. Most of them were of the comatose form; 
four only belonging to the strongly marked cold, or algid variety. 
In twenty-five or twenty-six cases, the prominent cerebral symp- 
toms, during the paroxysms, were stupor or coma, — the latter often 
profound in all, — in many, spasmodic contractions of the muscles 
of one or both arms; and in some few, delirium. The cerebral 
symptoms were also present in the algid cases, but less constantly, 
and less strongly marked. In seventeen of the thirty-one cases, 
in which the brain was examined, there was extensive or general 
inflammatory injection of what Bailly calls the arachnoid, mean- 
ing, I suppose, the pia mater. In many instances, this injection 
is described as intense, universal, and fine, extending to the 

' Amer. Journ. Med. ScL, April, 1S41. 2 ibid., April, 1846. 



LESIONS.— BRAIN. 325 

minutest capillaries, and resembling a beautiful anatomical pre- 
paration. In some cases, it was rather more strongly marked on 
one side than on the other. In two cases, the meshes of the mem- 
brane contained coagulated blood ; and in two or three, there was 
an effusion of fibrin e. In the remaining fourteen cases, the mem- 
brane is described as moderately or slightly injected ; in only three 
or four, was it natural. Another alteration consisted in a dark 
reddish brown color of the cortical substance of the brain. This 
was present and strongly marked in ten of the thirty-one cases, 
all of which were of the comatose form.^ In one case, of the 
algid variety, the cortical substance was paler than natural. In 
nine cases, sections of the brain were immediately covered with 
numerous bloody points from the orifices of the cut vessels : in a 
certain number, also, there was more or less venous engorgement 
of the superficial vessels, and a moderate accumulation of serum ; 
but all these changes are frequently found in other diseases, and, 

^ This alteration would seem to have been more frequent than is indicated by this 
proportion of cases in which it occurred. It is probable that Bailly mentioned it in 
his descriptions, only when it was strongly marked. It may be a matter of interest 
to my readers to see his remarks upon it. He i says: — "The brown color of the 
cortical substance was so generally present in those who perished with comatose 
fever, and in whom the coma returned with each successive paroxysm, during a 
great part of the summer, that I came at last so far to habituate myself to this shade 
as to consider it almost natural. Although I had formerly been especially occupied 
in France with the anatomy of the brain, and had thus familiarized myself with 
a type of the natural color of the cortical substance, as must always happen 
•with those who labor constantly upon any similar subject ; still the habit of seeing 
none but the brains of these comatose patients had at last substituted a new ty^e 
for the old one. I therefore seized every occasion that presented itself of comparing 
these brains with those of individuals who had died with other diseases; and then 
the enormous difference between the two classes became manifest. For pathological 
anatomy demands not only exterisive observations, but continual comparisons be- 
tween healthy and diseased organs. Show the brain of a person who has died with 
comatose congestive fever, to a physician but little in the liabit of examining brains, 
and very certainly he will consider himself authorized to deny the alteration, which 
is quite evident to one who is familiar with the natural appearance of this organ. 
During the epidemic constitution of the year 1822, at Rome, there were fatal cases 
of phthisis, aneurism, dropsy, and so on, in which the brain was not implicated. 
Now, the cortical substance of the brain in these cases, when placed by the side of 
that of the fever patients, as I have noted in many instances, appeared white. In 
many instances, tlie morbid condition of organs is so slight or obscure, that its exist- 
ence may be questionable; but this of which I am now speaking I have found so 
many times, and so constantly, and it has been so marked and evident, that not one 
physician in a thousand would have hesitated in admitting it." — Traite Anat.Path. 
des Fievres Inter. Par E. M. Bailly, de Bbis,p. 181. 



326 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

as has already been said, can hardly be regarded as peculiar or 
important. 

The following important additions to the pathology of the nerv- 
ous centres in periodical fever, mostly of the pernicious form, are 
derived from the excellent and accurate work of Maillot. He 
examined the brain and its membranes in twenty-seven cases. In 
five cases, he found general opacity of the arachnoid; in three 
cases, circumscribed opacity; in one case of icteric algid fever, 
the arachnoid had a yellowish tinge ; and in one case, where a 
quotidian fever had passed into a t}-phoid condition, the cavity of 
the arachnoid contained , a sero-purulent collection. In eleven 
cases, the j5ia mater was injected, more or less vividly, the arach- 
noid remainins: natural ; in six other cases, both membranes were 
the seat of a rermilion injection; in most cases, the vessels which 
run alons^ the surface of the brain were strongly congested ; many 
times the injection of the cerebral envelopes was sufficiently fine 
to form patches, more or less extensive, of a vivid and brilliant red. 

In twenty-two cases, the cerebrum was more or less strongly 
injected; in most instances, with a firmness and density that 
appeared to M. Maillot much greater than natural. Generally-, 
the substance of the brain exhibited a red color, very thickly 
dotted with bloody points ; in some cases, of comatose and deli- 
rious fever, the cerebral mass was so strongl}' congested, that 
when compressed, after having been diWded, the blood flowed 
copiously from the cut surfaces. In eight cases, the gray sub- 
stance had a very dark color; in five of them, approaching a 
blackish tinge ; in six cases, the choroid plexus was of a deep 
red color; in ten cases, the ventricles contained bloody serum. 
In one comatose case, the brain was strong]}- injected, but soft; 
in one icteric algid case, it was slightly injected, of natural con- 
sistence, and of a yellow color; in three other cases, it was 
slightly injected, but without change of color or consistence. 
The cerebellum exhibited changes analogous to thoseof the brain, 
but less frequent than these. 

In fourteen cases, the spinal pia mater was the seat of a ver- 
milion injection; in five cases, the pia mater and arachnoid were 
both injected; in one case of algid fever, both had a yellowish 
color; in one case, their condition is not mentioned. In four 
cases, the substance of the spinal marrow was generally injected, 
and firmer than natural ; in one case, it was less firm than natural ; 



LESIONS —LIVER. 327 

in one case, the injection was very sliglit ; in three cases, its 
consistence was natural, without any injection; in two cases, the 
injection was general, but it was much more strongly marked at 
the cervical and lumbar regions than elsewhere ; in one case, it 
had a yellowish tinge, without any other alteration ; in four cases, 
there was general injection, with red softening of the dorsal por- 
tion ; in three cases, there was white softening of the dorsal 
portion; in one case, there was white softening of the cervical 
portion; and finally in one case, the injection of the gray sub- 
stance, generally more considerable than that of the white, was 
very strongly marked in the cervical region, and carried to the 
red softening in the dorsal. In all these cases, death took place 
in the acute period of the disease. Maillot says in another place 
that these lesions are found in all the varieties of pernicious fever ; 
but that in the algid form he has found the cerebral congestion 
less strongly marked than in the comatose and delirious, while 
the spinal changes have been more so than in these. ^ In four 
cases, reported by Mr. Nepple, the lesions of the brain described 
by Bailly and Maillot, were not observed. In two cases, reported 
by M. Raymond Faure, they were present.^ 

The fine injection of the membranes, the dark color of the 
cortical substance, and the general vascularity of the brain, would 
seem to constitute sufficient evidence of the previous existence at 
least of a high degree of irritation, approaching and in some in- 
stances perhaps passing into actual inflammation. The same 
remarks may be made in regard to the spinal marrow, and its 
envelopes. 

ARTICLE III. 

LESIONS OF THE ABDOMINAL ORGANS. 

Sec. I. — Liver. I commence this article with a full account 
of the condition of the liver, because there is good reason for be- 
lieving that the lesions of this organ constitute the anatomical 
characteristic of the disease. For this discovery, and for the 
special attention which has recently been directed to the state of 
the liver in periodical fever, we are indebted to Dr. Thomas Stew- 
ardson, of Savannah, Ga. Dr. Stewardson, before leaving Paris, in 

* Traite, etc., p. 334. 2 Traite des Fievres Intermittentes, p. 283, et seq. 



328 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

1834, had been made acquainted with the observations of Louis 
on the state of the liver in all the fatal cases of yellow fever, exa- 
mined during the epidemic, in Gibraltar, of 1828; and on his re- 
turn soon after to America, he naturally felt a strong interest in 
ascertaining whether the same lesion was to be found in remittent 
fever, — a disease regarded by many physicians as a mere variety 
of yellow fever. Opportunities for determining this interesting and 
important point of pathology soon presented themselves, and were 
zealously and faithfully made use of. Cases of periodical fever^ 
in its several forms and degrees, are annually received into the 
Philadelphia Hospitals, coming mostly from certain localities in 
Pennsylvania, and from the southern ports of the Atlantic, and 
occurring amongst sailors. During the years 1838, 1839, and 
1840, there were seven cases of the disease, which terminated 
fatally, and in which autopsies were carefully made. The first 
examination was made on the 9th of September, 1838, seventeen 
hours after the death of the patient. The form of disease was that 
most nearly approaching yellow fever. The liver was of natural 
size, flabby, and of a bronze color, becoming livid in the small 
lobe ; internally it was of a uniform light bronze color. The acini 
were distinguishable hj a slight elevation, but there was no differ- 
ence of color in the two substances. The history of the condition 
of the liver is thus summed up by Dr. Stewardson: — " The liver 
was enlarged in three cases, and in one of them to a great degree ; 
in the others, it was of natural or moderate size. The consistence 
of the organ appears to have been generally diminished ; being 
flabby, or softened, or both, in four cases; a little soft in a fifth ; 
and moderately firm, but still readily penetrated by the finger, in 
a sixth; in a seventh, the consistence is not mentioned. The 
color was nearly the same in every case, but very different from 
natural. In most of the cases, the liver is described as being of 
the color oi bronze, or a mixture of bronze and olive; in one, as a 
dull lead color externally; internally bronzed with a reddish 
shade; in another, as between a brown and an olive, the latter 
predominating ; and finally, as a pale, slightly greenish lead color, 
with a tinge of brovm, in one instance. The most correct idea of 
the color before us would, perhaps, be conveyed by stating its 
predominant character, the same in every case, to be a mixture 
of gray and olive, the natural reddish brown being entirely ex- 
tinct, or. only faintly to be traced. This alteration existed uni- 



LESIONS.— LIVER. 329 

formly, or nearly so, throughout the whole extent of the organ, 
except in a single instance, where a part of the left lobe was of 
the natural reddish-brown hue. As the alteration of color per- 
vaded both substances, the two were frequently blended together, 
and the aspect of the cut surface remarkably uniform. In one 
case, however, there was a marked distinction of color, the olive 
being predominant in the parenchyma, the brown in the acini. 
Of the four cases in which these characters are mentioned, the 
cut surface is described as smooth in three ; of a shagreened ap- 
pearance, and rough in the left lobe, in the fourth. This last 
character was evidently dependent upon hypertrophy of the lighter 
colored substance, which existed also in another instance ; both 
cases, however, being examples of a very protracted form of the 
disease."^ 

In concluding the summary thus given, Dr. Stewardson very 
naturally suggests, at least, the strong probability, that this alter- 
ation of the liver may be found to constitute the essential anato- 
mical characteristic of marsh fever, as the lesion of Peyer's glands, 
and the lymphatic ganglia, constitutes that of typhoid fever. He 
very properly, however, admits that the number of cases is not 
sufficiently large to determine this point conclusively; and he re- 
fers its definitive settlement to future and more extended observa- 
tions. In this connection, he states, that in the only case of marsh 
fever, examined during the year 1840, at the Blockley Hospital, 
by Dr. Gerhard, the liver presented the appearances which have 
just been described. 

The investigations which have been made and published, since 
the appearance of Dr. Stewardson's paper, are the following. In 
January, 1844, Dr. Wm. T. Howard communicated to Dr. Stew"- 
ardson the history of a case which was observed in the Baltimore 
Almshouse, during the preceding season. ^' The liver was smooth 
externally, and of a uniform slaty, bronze color, marked with 
white striae through it. When cut into, it presented the same 
uniform slaty, olive, or bronze color, with the red and yellow sub- 
stances confounded together, so as not to be distinguished. It 
was moist when cut into, its vessels not much gorged with blood, 
and it was easily penetrated by the finger. No one portion was 
more changed than another."^ 

' Stewardson on Rem. Fever. Am. Jour. Med, Sci., April, 1841. 
2 Am. Journ. Med. Sci., Jan. 1845. 



330 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

Dr. Swett's cases, observed in the New York Hospital, have 
already been referred to. Five of them were fatal ; and in all, 
the peculiar change in the color of the liver, described by Dr. 
Stewardson, was present. Externally, this organ had a slaty and 
bronze tint, and an olive tint internally. Its volume was natural ; 
in four cases, it was sKghtly, or moderately, softened ; in some 
cases, the granular structure was less distinct than in a natural 
state, while in others, it was not altered; in one case, each gra- 
nule was surrounded by a ring of vascular injection. There was 
no unusual accumulation of blood. ^ 

Dr. Alfred Stille has published in the American Journal of the Me- 
dical Sciences, for April, 1846, brief histories of twelve fatal cases 
of remittent fever, which occurred during the summer and autumn 
of 1844, in the Baltimore Almshouse Infirmary, and which were 
reported by Dr. W. F. Anderson, and Dr. Charles Frick. Setting 
aside two of the cases, on account of some doubtful or qualifying 
circumstances in their history, the condition of the liver in the 
other ten is thus summed up by Dr. Stille. " The size of the 
liver was noted in nine cases, in all of which, it was unnaturally 
large. Its consistence was very much diminished in ten cases, 
in eight of which the right lobe was the principal seat of the alter- 
ation ; in one, the left lobe was chiefly affected, and in the re- 
maining one, the whole organ was softened. In all, the color of 
the liver was either bronzed, or like that oi slate; the surface of a 
section was polished, or shining; and in every instance but one, 
the different colors of its component parts could not be distinguish- 
ed."^ Dr. Stille remarks, in the number of the Journal which con- 
tains these histories, that the same condition of the liver has been 
found in numerous dissections made at the several public institu- 
tions of Baltimore, during the fever season of 1845. 

The result of Dr. Boling's observations can hardly be regarded, 
in the present state of our information upon this subject, as of any 
great value ; at any rate, these results are not sufficiently authen- 
tic and conclusive, to throw any reasonable doubt upon the con- 
clusions of Dr. Stewardson, Dr. Swett, and others. He says, that 
not havinor found the chancres in the liver which he had looked 
for, he was led to believe, that lesions of this organ were less fre- 
quent than of almost any other. On the appearance of Dr. Stew- 

* Swett on Path- Rem. Fev. Amer. Journ. Med. ScL, Jan, IS 45. 
2 Ibid., April, 1846. 



LESIONS.— LIVER. 331 

ardson's paper, his attention Avas again directed to the liver, but 
he has been able, he says, in but a very few instances, to find 
any alteration, the organ in a large proportion of cases, so far as 
he was capable of judging, being entirely healthy. Where it was 
otherwise, he found the concave surface of the liver of a bluish 
slate color. Dr. Doling does not give any detailed histories of his 
autopsies ; he speaks of himself as not accustomed to frequent 
post-mortem examinations; and, as I have already intimated, it 
will be considered, in the actual state of our knowledge, as a per- 
fectly fair judgment, that these cases shall, provisionally, at least, 
be set aside, and not be allowed to have any effect on the settle- 
ment of the question before us. Maillot describes the liver in nine 
cases, as congested; in three cases, as easily torn; in one case, as 
f liable; in three cases, as yellowish^ pale, and somewhat softened ; 
once, as greenish yellow; once, as chocolate colored; and, in five 
cases, as natural. In five other cases, its condition is not men- 
tioned.^ 

It would be hardly worth the time and room necessary for this 
purpose, to go into any detailed account of the pathological re- 
searches of older writers upon this family of diseases. The 
Italian authors, — Baglivi, Lancisi, Torti, Ramazzini, etc., — the 
great classics in this department of medicine, — are not at our 
hand; and if they were, they would be of little service, as they 
are said to give but meagre and unsatisfactory details in regard 
to the state of the organs after death. George Cleghorn, in his 
admirable little treatise on the diseases of Minorca, written a hun- 
dred years ago, says, that he had examined the bodies of near a 
hundred persons who had perished with tertian fevers, and had 
constantly found "one or other of the adipose parts in the lower 
belly, — the cawl, mesentery, colon, etc., — of a dark black com- 
plexion, or totally corrupted." Bailly, in his elaborate and 
interesting history of the pernicious intermittents of Rome, reports 
a large number of autopsies ; but in many of them, the liver is 
not mentioned ; in others, it is said to have been gorged with 
blood; and in others, it is called natural. It need hardly be said, 
that the overlooking by these writers, and under such circum- 
stances, of a lesion like that under consideration, is no proof that 
it did not exist. ^ 

* Traite des Fievres Intermittentes, p, 2S5. 

2 Prost is said to have exhibited the extensive intestinal lesions of typhoid fever, 



332 PERIOMCAL FEVEE-— BILIOCrS mEMITTEirT FOlLSf. 

There seeEis to be no mnfiHinitj in Ihe diarader of tiae Inle 

coiBtaiiaed in the gaD-bladdo-. Dr. Sttewaidson fimsd it generaEj 

abundant and Teij Said; wiMe in nsailj all die eases lepcnfed 
by Br. Swett, Dr, AndeiHso, and Dr. Fridk, it was darik, tbid^ 

and Tiscid, like m-olasses. BwMj irarely mcE^ns Ae ^^eaianee 
of ihe bile. 

As to the nature of the lesion of the Sfo- jnsi; described, it; is 
impossible, in the pre?^::' r :-• - ^f sdeaace, to say mncb, wilboat 
ninning into the mr: : : _ - "-^^' We bare no li^ift to con- 
sad-er it iaflaminatoiy. li iiihj Dt the lesolt of lepeafred conges- 
tions ; but it is more philosophical for the pieseni, to s^ am^ly, 
that it seems to be Jan gemeris^ — ^to consist in an alteraitioa of a 
special and peculiar ct "ir ~.'r."ije and mechanism rf 

T?rhi':L ?^e quite nnknoTr:. ;: I" i: nrobably connected in 

scz- : ^ ~rth the poison of : : : 7 : . — alike unknown to 

lis, — and it ma}^ be the resnli c: .7 'lis pcisan npim 

the system, or of the morbid proi^i;;: :: ^'_. :_ :_e pot's©!!! giTCS 



Sec. II. — Spleen. The spleen is almost always enlaiged, ser- 
ened, and of a xery dark, or blmdi blai^ cdor. Ibis lesiim is 
so constant, and :.. ~ t r ':: so loaig feimibar to all obserreis of this 
class of disease I, :__: .: is hardly nece^aiy to mnllliply cases, imt 
to quote aiathonities. In some instancses, the T«dame of lik^ <»^atn 
is enoimonsly increased. In one erf Drs. Anderson and Flick's 
cases, it weighed thi^ee pounds; in one of Dr. Swett's cases, it 
was nine inches long and j^mr tbic^ Bailly inpiitfioiis! instances 
of its weighing eight or nine - : " ■ It isd&en so mndk softened 
as to consist merely of a sort c : _: . : : . : 3 putiilage, — a daik pulpy 
mass apparently destitute of orr; .. : ; : :.. Dr. Bailly repoitf 
sexeral cases in which ti7-T :".;.: '7 -r'-'z of tbe oigan 

resulted in a rupture of 1:1 r_~ :. : _■ _„7„- : .7. and the con- 
sequent escape of its softened coi-T -. :.. " : . i" : " . . -. al caTity. 
Maillot saw but one instance of r: : - ; : .. : . 771 . Africa. 
He suggests that its greater frequei^ij 11. I\ ." .^: ' .7 7.: „ ir-on 
the less aetixe means adopted there to pre" 7 " ! . ; : _ - ^ 
Dj. Boling thinks that these alterations of .17 : /.7 7:_ ::- 7 
the consequence of what he calls the laiti:: 1:. ::. 

in bodies "wTiicli had "been examined bj Piael and CcmrasE:- ::._ -.t :."t:-;-:j:c.- 
"srlioliy orerlooted. 



LESIONS.— STOMACH. 333 

than the immediate and direct result of the disease. He says he 
has never found any evidences of enlargement during life, nor 
any morbid appearance in the organ after death, in a first attack 
of remittent fever, in a person who had not previously resided 
some considerable time in a malarious region. He believes the 
alterations to take place gradually from the efTects of the febrile 
poison upon the system, and that they are merely increased by 
the febrile attack itself.^ This condition of the spleen is probably 
the result of violent and repeated congestions. 

Sec. hi. — Stomach. The condition of the stomach has not 
been ascertained with a sufficient degree of accuracy, and in a 
sufficiently large number of instances, to settle definitely the part 
which its lesions play in the pathology of remittent fever. Its 
mucous membrane presents, in a large majority of cases, marks 
more or less extensive and striking, of inflammation. It is 
generally reddened and vascular; sometimes, over certain por- 
tions only, and at others, throughout the whole extent of its sur- 
face. This redness is sometimes continuous and uniform, some- 
times in patches; in some cases arborescent, and in others, 
pointed, or dotted. The consistence of the membrane is also 
sometimes diminished ; and in many cases, it is mamellonated. In 
five, of six cases reported by Dr. Stewardson, marks of inflam- 
mation were present; — mamellonation, in three; thickening, in 
two; thinning throughout, in one; in the great cul-de-sac^ in an- 
other; softening in two, and changes of color in several. In one 
or two instances, the lesions were very slight.^ The membrane 
was injected in seven of nine cases reported by Anderson 
and Frick, — in three of them intensely. In five cases, it was 
softened near the cardiac extremity, and in four, near the pylorus; 
where, also, it was for the most part, grayish, thickened, and 

' This opinion of Dr. Boling induces me to record here, in a note, a pathological 
fact that may have some bearing upon the subject. During the winter of 1844, a 
patient died in the Baltimore Almshouse with simple pneumonia. He came from 
the Mine Banks., a locality celebrated for the number and severity of its marsh 
fevers. He had resided there during the sickly season, but was not known to 
have had the fever. In addition to the lesion of the lungs, his liver presented the 
alterations already described, as belonging to remittent fever. I suggested at the 
time the possibility at least, that the change in the liver might have been the result 
of the gradual and long continued action upon the system of the febrile poison. 

2 Amer. Jour. Med. Sci., April, 1841. 



334 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

mamellonated.i Dr. Swett found nearly similar alterations ; but he 
is disposed to regard them as less important than they are con-^ 
sidered to be by Dr. Stewardson. "Most of the changes,"— he 
says, — "that I have observed in the mucous membrane of the sto- 
mach have appeared to me of a chronic nature, and probably long 
antecedent to and entirely independent of the acute disease. I refer 
particularly to the thickened and mamellonated condition of the 
organ. The injection of the mucous membrane, although present in 
all the cases to a certain extent, did not appear to me beyond what is 
commonly noticed in other acute diseases, and might, in some cases, 
at least, be referred distinctly to simple post-mortem venous con- 
gestion."^ Of thirty-one cases of malignant intermittent, or con- 
gestive fever, occurring at Rome, and reported by Bailly, the 
stomach is described as presenting marks of inflammation, more 
or less extensive and intense, in twenty-six ; in some cases, the 
mucous membrane was thickened ; in some mamellonated, and in 
many, thickly covered with a layer of viscid, tenacious mucus, 
adhering pretty firmly to the membrane itself.^ The stomach is 
not unfrequently contracted upon itself, its inner membrane 
thrown into prominent folds, and its cavity containing a moderate 
quantity of fluid of a yellowish, brownish, or greenish color. 

Maillot examined the mucous membrane of the stomach care- 
fully in twenty-eight cases, most of them belonging to the perni- 
cious form of the disease. In only one, was the membrane en- 
tirely healthy. In five cases, he found gray, slate-colored 
softening, without any red injection; in one case, gray, slate- 
colored softening, with pointed redness; in eleven cases, gray, 
dirty softening, with red injection; in one case, gray, dirty soft- 
ening, without redness ; in four cases, reddish softening ; in two 
cases, reddish-brown softening; in one case, blackish softening, 
without injection; in one case, where death was occasioned by 
rupture of the spleen, very slight recent injection, with a gray 
tint; and in one case of typhoid affection, the red injection, with 
softening, common in acute gastro-enteritis. I have already 
spoken of Dr. Swett's opinion in regard to the character of these 
gastric lesions. Maillot has arrived at a similar conclusion. He 
thinks it quite clear, that in most cases, the alterations, especially 
the softening with gray, brown, and slate coloration, extending to 

1 Amer. Jour. Med. Sci., April, 1846. 2 Ibid., Jan. 1845. 

3 Bailly on Inter. Fevers. 



LESIONS.— INTESTINES. 335 

large portions of the membrane, are the result, not of recent acute 
inflammation, but of chronic irritation, preceding the attack of the 
febrile disease. The difference between the result of his obser- 
vation and that of Bailly's he believes to be more apparent than 
real. 

Sec. IV. — Intestines. Although our knowledge of the lesions 
of remittent fever is far enough from being full and complete ; and 
although there are some apparent differences in the results of re- 
cent observation in regard to the condition of the mucous mem- 
brane of the alimentary canal, we are justified, I think, in saying 
that there is no satisfactory evidence that this membrane is the 
seat of any constant, important, or characteristic alteration. Dr. 
Stewardson has called the attention of the profession to a condi- 
tion which he supposes may be peculiar to this disease; — I mean 
an enlargement of the mucous follicles of the duodenum, or the 
glands of Brunner, as they are called. He found these glands 
remarkably distinct in all the six cases, where the duodenum was 
particularly examined.^ In all the twelve cases reported by Ander- 
son and Frick, Brunner's glands were also unusually developed, 
and in three of them, to a remarkable degree.^ Dr. Swett, on 
the other hand, did not find, in his five cases, any change in the 
state of these glands, which he could look upon as morbid.^ 

The elliptical plates of the small intestines, commonly called 
Peyer's glands, are, so far as the most authentic and trustworthy 
observation enables us to determine, umf or mly free from any well- 
marked morhid alteration. This, at any rate, is the conclusion 
which I myself, in the present state of our knowledge, and after 
a careful examination and estimate of all the evidence within my 
reach, feel compelled to adopt. But as the question of the con- 
dition of these glands is one of so much pathological interest and 
importance; as it has a direct bearing upon the relations of bilious 
remittent to other forms of fever, and as it may fairly enough be 
regarded as not finally and definitively determined, I will state 
briefly, but completely, the results of recent observation upon this 
matter. Dr. Gerhard examined particularly and carefully the 
state of Peyer's glands, in two cases of remittent fever, as long 
ago as 1834 ; and he found them in both entirely free from the 

» Amer. Jour. Med. Sci., April, 1841. 2 Ibid., April, 1846. 

3 Ibid., Jan. 1 845. 



336 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

slightest alteration. In the seven fatal cases which constitute the 
material and basis of Dr. Stewardson's paper on the lesions of this 
disease, the glands of Peyer were uniformly healthy. They are 
described in some cases as distinct, and well defined in their out- 
line, honey- combed on the surface, or dotted with depressed points, 
and these latter sometimes of a dark color; but uniformly free 
from thickening, softening, ulceration, or any other obvious and 
unequivocal alteration.^ In Dr. Swett's cases, — " the glands of 
Peyer were very distinct from their pale white color, contrasting 
strongly with the dirty hue of the surrounding mucous membrane, 
but neither thickened, softened, nor injected."^ In two of the 
twelve cases reported by Anderson and Frick, the elliptical plates 
were either not examined, or are not mentioned ; in the remaining 
ten, they were generally pretty distinctly visible, but free from 
any decided disease.^ 

These results may seem to be in contradiction to certain other 
observations on the same subject. In the JVew York Journal of 
Medicine and Surgery, for 1839, Dr. Richardson, resident physi- 
cian of the New York Hospital, has published the pathological 
histories of six cases of what was regarded by him as remittent 
fever ; in all of which, Peyer's glands are alleged to have been 
diseased. In three, they are said to have been enlarged, but not 
ulcerated; in one, there were numerous small ulcers on one of the 
plates ; and in two, there were more or less extensive and unequi- 
vocal ulcerations, — the ulceration in one of these having extended 
through all the coats of the intestine. My attention was called 
to these cases, by a medical friend, very soon after their publica- 
tion, on account of the contradiction which they appeared to fur- 
nish to one of the most generally received and well established 
opinions in regard to the intestinal lesions of typhoid and of remit- 
tent fever. I studied them with great interest, and with great care ; 
and was immediately and thoroughly convinced that the deduc- 
tions which had been made from them were wholly gratuitous and 
unfounded. It was quite clear, that in the two cases, in which 
extensive and unequivocal ulceration was present, either the 
diagnosis was manifestly wrong, or there was no sufficient ground 
for regarding them as cases of remittent fever; while in all the 
others, in which the diagnosis was most probably correct, there 

1 Amer. Jour. Med. Sci., April, 1S41. 2 Ibid., Jan. 1S45. 

3 Ibid., April, 1846. 



LESIONS.— PEYER'S GLANDS. 337 

was no sufficient evidence of any morbid condition of the ellipti- 
cal plates. This whole matter has since been placed in its true 
light, and the importance of these cases reduced to its proper 
position, by Dr. Swett, in the American Journal of the Medical 
Sciences for January, 1845. If these cases do not furnish any 
additional evidence of the wide difference between typhoid and 
remittent fever, so far as the condition of Peyer's glands is con- 
cerned, they do not at least furnish any evidence of a contrary 
character. They have one value, however; and that consists in 
the lesson they teach us, — a lesson that can hardly be too fre- 
quently or too emphatically repeated, — of the great danger, in all 
questions requiring careful observation and rigorous analysis, of 
trusting, in any, the slightest degree, to incomplete, inadequate or 
equivocal facts. Such facts, under such circumstances, so far as 
the interests of true science are concerned, are worse than none, 
inasmuch as ignorance is better than positive error; and as it is 
safer and more profitable to stand still in the dark, than it is to 
follow a false light in the wrong direction. 

Dr. Boling reports two cases in which he found ulceration of 
the elliptical plates. The history of the cases is not given ; but 
in one of them, we are told that the fever w^as of about forty days' 
duration; in the other, the case terminated on the ninth day, and 
was attended by diarrhoea. I have already had occasion to express 
the opinion that some of the cases alluded to by Dr. Boling, in 
his description of the symptoms of bilious fever, were cases of 
typhoid fever; this I believe also to have been true of the tw^o 
cases just spoken of. At any rate, the most that we can do with 
them is, to set them aside, or to place them in the category w^ith 
those of Dr. Richardson.^ 

As to the mucous membrane generally, both of the small and 
large intestines, there is no evidence that it is more than occa- 
sionally and accidentally altered. Bailly describes it, in most of 
his cases, as more or less extensively inflamed ; and the same 
thing is true of some other observers. It is quite clear, however, 
that in many of Bailly's cases, the presence of a few patches of 
increased redness or vascularity was the only proof of the pre- 

^ Since writing the above I have had a correspondence with Dr. Boling in regard 
to the most striking of these two cases. His letter to me contains nothing to induce 
me to change the opinion already expressed in regard to the true character of these 
cases. 

22 



338 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

rious existence of inflammation. According to the researches of 
all the more recent and accurate observers, the changes found in 
the general intestinal mucous membrane, after death from periodi- 
cal fever, are only those customary and accidental lesions, found 
with the same frequency, after death from many other acute febrile 
affections.^ I am not aware that there is anything peculiar in 
the contents of the alimentary canal. The mesenteric glands are 
generally without alteration ; the same thing is true of the kidneys 
and the bladder. 

ARTICLE IV. 

GENERAL REMARKS. 

Sec. I. — Relation of Lesions to Symptoms. It is sufficiently 
demonstrated by the foregoing details, that periodical fever does 
not often destroy life without leaving behind it very decided and 
somewhat extensive anatomical lesions. As I have done, in re- 
gard to the fevers already treated of, I propose here to say a few 
words about the connection between the symptoms of the disease, 
on the one hand, and these lesions, on the other. This connec- 
tion, so far at least as the more constant and important pathologi- 
cal alterations are concerned, would seem to be pretty uniform 
and direct. We can hardly hesitate, I think, for instance, in 
referring the nausea, vomiting, and epigastric distress, so nearly 
always present, to the disorders of the mucous membrane of the 
stomach, resulting in the changes that are found after death. So, 
the moderate fullness across the upper part of the abdomen, with 
the tension, the feeling of weight, and oppression, in each hypo- 
chondrium, and especially in the left, are evidently connected 
with, and dependent upon, the congestion of the liver and spleen, 
resulting in the alterations which these organs constantly exhibit. 
In the same way, it is impossible to doubt, that the coma and 
delirium are intimately and directly connected with the striking 

* jMaillot found, in fifteen cases, the mucous membrane of the small intestines 
softened, with a gray, brown, or slate tint, with or without recent injection ; in one 
case, softened, %vith bright redness: in twelve cases, the elliptical plates with the 
honeycomb development, in three of which the surface of the plates resembled the 
newly-shaven chin ; in eleven cases, some development of the isolated follicles : 
once, only, ulcerations; in four or five other cases, slight changes; and in four cases 
no lesions whatever. — Trait e des Fievres Intermittentes, p. 284. 



LESIONS.— GENERAL REMARKS. 339 

lesions usually found in the brain and its membranes ; and if the 
relationship, here, sometimes fails, — if it is not absolutely inva- 
riable, — this is only what happens occasionally, even with the 
best established and most constant of these relations, in other dis- 
eases. M. Maillot thinks that the algid symptoms, — the failing 
circulation, and the icy coldness, — are especially and immediately 
connected with the lesions found in the spinal marrow and its 
membranes.^ 

I do not see any reason to suppose that the lesions of periodical 
fever follow any fixed or uniform order of succession in their de- 
velopment. The congestions and irritations of the several organs 
and tissues, which bear the chief burden of the disease, are in 
many cases, evidently simultaneous in their origin — occurring 
together ; in others, the weight of the disease, to use the favorite 
phraseology of the older WTiters, falls principally upon one organ, 
— the brain, for instance ; in still others, upon some other organ, 
— the stomach, the liver, or the spleen ; — and all this, without 
anything that is constant or regular. 

Sec. II. — Importance^ — Relative, and Absolute. The relative and 
absolute importance of the appreciable lesions in periodical fever, 
— the part which they severally play in the production of the 
aggregate phenomena of the disease, and the share which each 
of them contributes towards the fatal issue, in fatal cases, are 
matters which can be only approximatively, and in some degree 
conjecturally, determined. We can hardly doubt that a sudden 
and overwhelming congestion of the cerebro-spinal axis will be 
attended by greater danger, than a corresponding congestion of 
the liver and spleen ; but to attempt to go much beyond a few 
obvious and manifest conclusions, similar to this; and nicely to 
guage and measure the agencies of each pathological alteration, 
would be but an idle and profitless labor. 

* Traite des Fievres Intermittentes, p. 329. 



340 



CHAPTER IV. 

CAUSES. 

Sec. I. — Locality. There is, probably, no form of endemic 
disease, the geographical boundaries of which are so extensive, 
as those of periodical fever. With certain limited exceptions, it 
may be said to encircle the earth, in a broad belt, parallel with 
the equator, its northern and southern boundaries quite irregular 
in their disposition, — now approaching to the line of the tropics, 
and now receding from it. The portions of this immense territory 
which are entirely exempt from periodical fever increase with 
the distance from the equator; while, within the tropics, and 
along the range of several degrees beyond them, these portions 
are confined mostly to certain geological formations, and to ele- 
vated situations. The particular regions, most extensively and 
constantly the seat of this disease in its more malignant forms, 
are low-lying and wet lands, situated in hot climates, and covered 
with a rank and spontaneous vegetation, — the flat, wooded, sea- 
coasts ; the interior swamps and marshes ; and the rich alluvions 
of the deltas and courses of the great rivers. It is hardly worth 
w^hile to make a detailed enumeration of all these individual locali- 
ties. I shall confine myself to a few statements in reference to 
the distribution of malarious fevers throughout the diflferent por- 
tions of the United States, for which I am mostly indebted to the 
researches of the late Dr. Forry. 

These statements are founded upon data furnished by official 
records in the Medical Department of the United States, and in 
the Adjutant General's office. They extend over a period of ten 
years; and they exhibit the actual and relative prevalence of 
periodical fever, amongst the soldiers in the several military sta- 
tions of the country. In these several classes of stations, the 
ratio of cases, annually, of intermittent fever, in each one thou- 
sand of mean strength, was as follows : — On the coast of New 
England, 36; — on the northern chain of lakes, 193; — in posts 



CAUSES.— LOCALITY. 341 

• 

north of latitude 39°, and remote from the ocean and inland seas, 
151 5 — on the sea-coast, from Delaware bay to Savannah, 370 ; — 
in the southwestern stations, including Jefferson barracks. Forts 
Gibson, Smith, and Coifee, Towson, and Jessup, 747; — on the 
lower Mississippi, 385; — and in the peninsula of East Florida, 
520. These averages, derived from sufficiently large numbers, 
and running through a period of ten years, with one or two ex- 
planations and qualifications, may be safely taken as a true 
exponent of the relative prevalence of this form of fever, in these 
several regions of country. The apparent ratio, in the New Eng- 
land division, low as it is, is still vastly too high ; since all or 
nearly all these cases originated in some of the other divisions. 
It may be remarked here, incidentally, that Nova Scotia and New 
Brunswick, in the British dominions, are entirely free from inter- 
mittent fever, while in Upper Canada, the disease prevails very 
extensively, although there is no difference in the climate, or soil, 
of these regions, to account for the circumstance. 

The ratio of remittent fever, according to Dr. Forry, throughout 
the same regions, is as follows : — on the coast of New England, 
26; — on the northern chain of lakes, 33; — in posts north of lati- 
tude 39°, and remote from the ocean and inland seas, 24; — on 
the sea-coast from Delaware bay to Savannah, 181 ; — in the 
southwestern stations, 180 ; — on the lower Mississippi, 196 ; — in 
East Florida, 102. The diagnosis, in the present case, is less to 
be relied upon, than in that of intermittent fever; it is probable 
that most of the cases reported in the New England division were 
continued, in their type, and not periodical. 

The only considerable portion of the vast and various territory, 
now occupied by the United States, which is quite exempt from 
malarious fever, is to be found in its extreme northeastern corner, 
constituted by the five New England states, and a large part of 
the state of New^ York. From nearly the whole of this region, 
periodical fever has almost entirely disappeared. That it was 
sufficiently common here for a long period after the settlement of 
the country has been clearly shown, by the very careful and 
thorough inquiries of Dr. 0. W. Holmes, contained in his prize 
essay upon this subject. There are still a few small localities, 
mostly along the valley of the Housatonic, in Massachusetts, where 
a solitary case, of domestic origin, may be still occasionally met 
with ; but with these exceptions, the disease is never seen in any 



342 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

of the New England states. Throughout the remaining portions 
of the country, the disease prevails with great irregularity of ex- 
tent and severity. Large portions of some of the states, — those 
particularly which are most thoroughly cultivated, and the higher 
granitic regions, with the dry, pine country of the south, are to a 
great extent free from the disease ; and this freedom is gradually 
extending its area with the progress of cultivation.^ 

As a general rule, the simple intermittent form of the disease 
predominates throughout the cooler and more temperate regions ; 
in the warmer climates, and during the latter part of the hot sea- 
son, the bilious remittent variety becomes more common, inter- 
spersed with occasional cases of the pernicious or congestive 
variety, — the latter becoming more frequent in the more southern 
regions, and especially along the low, rich, river bottoms, and 
swampy lagunes. Dr. Lewis, of Mobile, says, the low lands in 
the state of Alabama, lying along the creeks, known as the slough 
prairie, the swamps, and reed marshes, have proved to be more cer- 
tain and prolific sourcesof disease than other formations, — the low 
alluvions of the river bottoms not excepted. Some of these 
localities, as the reed marshes in Green county, though very fertile, 
have been abandoned. There are said to be farms, near the junc- 
tion of the Bigby and Alabama rivers, upon which no white man 
can permanently reside.^ 

There are many other regions where the disease is not less 
common and malignant. Lind says, Hungar}' has been properly 
called the grave of Germany. A ver}' striking instance of the 
power and intensity of the febrile poison, on the western coast of 
Africa, will be found in the chapter on bibliography. Dr. Nicolle, 
in a report made in 1821, says, — about one in twelve, or very 
nearly nine per cent, of the better class of society, died last year 
in Sierra Leone ; and it appears from official documents in the 
office of the secretary of government here, that such has been the 
average annual mortality from the census of Europeans in this 
colony. On the 31st of December, 1818, there were one hundred 
and twenty-eight, of whom, eighteen sailed before the rainy season, 
for England, two of whom died; and of the remaining number — 

1 At the beginning of the present centun^, of one hundred men emploved at the 
Onondaga saltworks, in Xew York, ninet}' -eight were attacked with bilious remitte..: 
fever. Many of the cases were fatal. — Edward Miller's Works, p. 97. 
. i Lewis's 3rled. His. of Alabama; p. 16. 



CAUSES.— SEASON.— TEMPERATURE.— WEATHER. 343 

one hundred and ten — eight perished.^ Mr. Tidlie says, — " The 
exceptions are very few, where Europeans have passed twelve 
months in the country from England without an attack of the 
fever. In the year 1819, there were, at Cape Coast Castle, eight 
new comers from England, all of whom were seized with the fever, 
and three died ; and out of forty, the total strength of Europeans 
in the service of the late African company, five died. In 1820, 
and 1821, there were eleven new comers, all of whom were at- 
tacked, and four of whom died."^ 

Another of the most celebrated malarious regions of the old 
world is to be found in the middle and southern portions of Italy ; 
and hardly in Africa itself, along the delta of the Niger, is the 
malarious poison more concentrated and malignant than it is here. 
Many a traveller has lost his life by a night ride over the Pontine 
marshes. Bailly estimates that one-tenth of the population of 
Rome are annually attacked by disease, and that two-thirds of 
these suffer from periodical fever. Some of our best and earliest 
histories of the disease were from Italian pens, — those of Torti, 
Lancisi, Ramazzini, &c. In 1818, there were consumed at the 
hospital of the Holy Spirit, at Rome, between the months of June 
and October, inclusive, three thousand and two hundred pounds 
of cinchona.^ 

Sec. II. — Season; Temperature ; Weather. There can be no 
doubt, as I have already said, that, other things being equal, 
periodical fever increases in frequency and gravity, with an in- 
crease in the heat of the climate or locality. The simpler and 
milder form of the pure intermittent type is most common in the 
more northerly and cooler regions, and in the cooler seasons of 
the year ; while the remittent and congestive forms are mostly 
confined to the hotter regions and seasons. M. Maillot shows 
conclusively, by extensive and accurate tables, that the frequency 
and intensity of visceral irritations and congestions increase in a 
constant and direct ratio with the elevation of the atmospheric 
temperature. He says, further, that the dry and hot season, in 
Africa, is marked by irritations of the brain and of the upper por- 
tion of the alimentary canal, while the wet season brings with it 
bronchitic and dysente.ric complications. "* 

i Boyle's Dis. West. Africa, p. 149. 2 Ibid., p. 152. 

3 Traite, etc., par Bailly, p. 139. 

4 Traite des Fievres Intermittentes. Par F. C. Maillot, p. 20. 



344 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

Throughout the United States, the great season for all the forms 
of periodical fever may be said to extend from the middle of sum- 
mer to the close of autumn, — varying, of course, somewhat, in 
different years and in different places. Dr. Wilcocks treated, 
during the season of 1846, in Philadelphia, one hundred and 
seventy-one cases of remittent and intermittent fever; — in July, 
ten cases; in August, eleven ; in September, ninety-nine; and 
in October, fifty-one.'^ On the western coast of Africa, the largest 
number of cases occur near the commencement and the termina- 
tion of the rainy season, — March and September.^ At Rome, the 
disease prevails most extensively during the months of August, 
September, and October.^ 

In regard to the influence of the prevailing character of the 
season, there is a general impression that hot and wet weather 
promotes the prevalence of marsh fevers, while cool and dry 
"weather prevents it. This impression is probably in some degree 
well founded ; although the connection between the obvious quali- 
ties of the season, and disease, are far enough from being fixed 
and uniform. Some observers, indeed, deny this connection 
altogether. 

Dr. Cooke, of Opelousas, in a paper on congestive fever, says, 
"We have seen our country enjoying one year extreme good 
health, notwithstanding the long continuance of the most intense 
heat, superabundance of rain, and easterly winds ; — another year, 
under similar circumstances, it has been ravaged by disease; — 
other years, when anticipating good health, in consequence of a 
moderate temperature, a uniform season, and moderate rains, 
without prevailing east winds, we have also had to sustain the 
most extensive visitation of disease. No one, in this section of 
the country, resting on experience or observation, c^n designate 
any infallible circumstances, as productive or promotive of sick- 



Sec. III. — -y^ge. The influence of age upon the occurrence of 
malarious fever does not seem to have been very particularly 
studied. It certainly may occur at all ages. It is more common 
during adult life, than it is earlier; and this may in part at least 
depend upon the greater degree of exposure. Cleghorn says, 

* Amer. Jour. Med. Sci., Jan., 1847. 2 Boyle's Dis. West. Africa. 

3 Bailly, p. 134. 4 N. O. Med. Jour., vol. ii. p. 180. 



i 



CAUSES.— SEX.— RACE. 345 

malignant tertians are most common amongst adults, and those of 
an advanced age.^ Dr. Charles Parry, in his paper on Congestive 
Fever, says, — "this disease is confined chiefly to adults of both 
sexes ; children are rarely affected. I never saw a case in an 
individual under twenty years of age."^ Dr. Wharton, of Mis- 
sissippi, says, of congestive fever, — "children under ten years of 
age are comparatively free from its ravages ; and persons from 
twenty to thirty are most subject to it.'" Dr. Lewis, of Mobile, 
on the other hand, thinks that the liability to congestive fever is 
alike at all ages, and that its greater frequency amongst male 
adults is entirely owing to the greater and more frequent exposure 
of this class to the malarious poison.^ 

Sec. IV. — Sex. There are more cases of periodical fever, in 
all its forms, amongst males than amongst females ; but the differ- 
ence in the degree of exposure of the two sexes to the causes of 
the disease are sufficient to account for this result. 

Sec. V. — Race. The negroes of malarious regions are less sub- 
ject to their fevers than the whites. 

Dr. Lewis, in his paper on the yellow fever of Mobile, makes 
the following remarks, in connection with this subject : " I will 
now travel so far out of my course as to give a few of the facts 
which have been gathered concerning the liability of the negro 
race to other diseases indigenous to Alabama. I practised two 
summers in the interior of the state; during the autumnal months, 
congestive fever prevailed so generally in my neighborhood as to 
amount to an epidemic ; — there were in my professional circle two 
blacks to one white, yet I did not see a single case of congestive 
fever in a negro, nor did I hear that any died of the disease in that 
section of country. I have made inquiries of several medical gen- 
tlemen who have been practising for many years in the country; 
their experience does not materially differ from mine. The fact 
is, that the remarkable exemption from yellow fever, v/hich this 
race enjoys, extends, in a great measure, to all the malarious 
fevers of hot climates ; — ^they may all have intermittent and light 
bilious fevers, as well as the milder grade of yelJow fever, but it 
is only under extraordinary circumstances that these diseases 

' Rush's Cleghorn,p. 106. 2 Amer, Jour. Med. Sci., July, 1843. 

" Ibid., April, 1844. 4 Med. Hist, of Ala., p. 26. 



346 PERIODICAL FEVER. 

affect them so seriously as to cause death. "^ The same writer, 
in his Medical History of Alabama, speaking of congestive fever, 
says,—" Of twenty-five correspondents, residing in different sec- 
tions of the state, two-thirds aver, that, with the limited exposure 
to which the whites are subjected, negroes would not have the 
disease." A very striking instance of the exemption of the negro 
race from these forms of disease is found in the history of the late 
disastrous expedition of the British government up the Niger, no- 
tice of which will be found in the chapter on bibliography. 

Sec. VI. — Exposure; Excesses, 4'c. There is no room what- 
ever to doubt the agency of the ordinary exciting causes of dis- 
eases, in bringing on an attack of marsh fever. The poison of the 
disease very frequently lies dormant in the system, until it is 
suddenly kindled into activity by the action of some one of these 
causes. The most active and important amongst them are, ex- 
posure of the body to cold, after it has been heated ; exposure to 
intense heat; fatigue; and all excessive indulgences. 

Sir Gilbert Blane says, — " If I were required to fix on a circum- 
stance, the most pernicious of all others to Europeans, particu- 
larly those newly arrived in the West Indies, I would say, that it 
is exercise in the sun. The practice most hurtful next to this, is 
intemperance in drinking, and to one or both of these the sickness 
and mortality amongst new-comers may be ascribed."^ 

It is important, however, to add, that where the poison of the 
disease is very active and concentrated, it overbears all resisting 
influences, and does not require the co-operation of any of these 
occasional causes. Hillary, in his account of the diseases of 
Minorca, says, — " Surprising as it may appear, it is nevertheless 
true, that the peasants, who are remarkable for temperance and 
regularity; and the soldiers, who, without meat and clothes, fre- 
quently lie abroad drunk, exposed to all weathers, have diseases 
almost similar, both as to tbeir violence and duration. Hence it 
is evident how far the power of the air is superior to that of the 
other non-naturals in producing disorders of the animal economy."^ 

Sec. Vn. — Malaria. The essential, efficient, producing cause 
of periodical fever, — the poison, whose action upon the system 

' X. 0. :\Ied. Jour., vol. i. p. 416. 

2 Obs. Dis. of Seamen, p. 226. 3 Rush's Hillary, p. 42. 



CAUSES.— MALARIA. 347 

gives rise to the disease, — is a substance, or agent, which has re- 
ceived the names of ma la nay and marsh inias?n. The nature and 
composition of this poison are wholly unknown to us. Like most 
other analogous agents, — like the contagious principles of small- 
pox, and typhus, and like the epidemic poisons of scarlatina, and 
cholera, — they are too subtle to be recognized by any of our 
senses; they are too fugitive to be caught by any of our contri- 
vances. Neither the strongest lenses of the microscope, nor the 
nicest analyses of chemistry have succeeded in discovering the 
faintest traces even of the composition and character of these in- 
visible, mysterious, and stupendous agencies. As always happens 
in such cases, and under similar circumstances, in the absence of 
positive knowledge we have been abundantly supplied with con- 
jecture and speculation; — what observation has failed to discover, 
hypothesis has endeavored and professed to supply. It is quite 
unnecessary even to enumerate the different substances to which 
malaria has been referred. Amongst them, are all the chemical 
products and compounds possible in wet and marshy localities ; 
moisture alone; the products of animal and vegetable decompo- 
sition ; and invisible, living animalculse. 

In regard to the alleged agency of animal and vegetable de- 
composition in the production of the poison of periodical fever, I 
have but little to say, and this for the simple but sufficient reason, 
that we have no positive know^ledge upon the subject. Unques- 
tionably, there is a very active decomposition, both of vegetable 
and of animal substances, usually going on in malarious locali- 
ties ; it is possible enough that this decomposition may produce 
the poison ; but there is no positive evidence yet that it does so ; 
and there are some reasons for doubting it altogether. One of 
these reasons is to be found in the common and notorious fact, 
that this same decomposition is constantly going on without giving 
rise to periodical fever.^ The hypothesis of the animalcular origin 
of this, and of some other endemic and epidemic diseases, is an 

' Bailly says, that in 1822, Rome was visited by immense numbers of large 
grasshoppers, so that the streets and fields were covered with them, living and 
dead ; but that the fevers of the country were much less extensively prevalent than 
during the previous year. He says also that the Ghetto in Rome, — the Jew's quar- 
ter, — is excessively filthy, — the narrow streets covered with decaying animal and 
vegetable matters, — but that it suffers much less from endemic fever than the more 
open, cleanly, and aristocratic neighborhood of the Vatican. — Traite des Fievres, etc. 
ParE. M. Bailly, p. 125, 



348 ■ PERIODICAL FEVER. 

old one, which has been recently revived, and advocated with 
great ingenuity and ability. It is only a hypothesis; but it may 
be safely said of it, I think, that it may be made to correspond to 
the ascertained phenomena in connection with the etiology of 
these diseases, better than most other hypotheses; and that it is 
less embarrassed by objections which cannot be met, and by diffi- 
culties which cannot be overcome. 

Inscrutable, however, as the intimate nature of this substance 
or agent may be, there are some few of its laws and relations 
w^hich are very well ascertained. One of these consists in its con- 
nection with low and wet, or marshy, localities. This connection 
is not invariable and exclusive, — that is, there are marshy locali- 
ties w^hich are not malarious ; and there are malarious localities 
w^hich are not marshy, — but there is no doubt, whatever, that it 
generally exists. The terms marsh miasm, and marsh fever have 
oriofinated from this circumstance. 

Again, it is quite certain, that the malarious poison may be 
transported by the atmosphere to a considerable distance from the 
place of its origin. M. Rigaud de I'Isle says: — "About the end 
of 1810, I was at Civita Vecchia, in Italy. Passing through St. 
John's place, which is a pretty regular square, I w^as shown . one 
whole side w^here the inhabitants had been much afflicted with 
diseases occasioned by bad air, w^hile those on the opposite side had 
almost escaped. What could be the cause of such an extraordi- 
nary difference between houses so near to one another? Dr. Nucy, 
an intelligent physician, pointed out to us that the former faced 
the south, so as to receive, directly, the south-east w^inds, which, 
arrive saturated with miasmata from the marshes on the coast. "^ 
A similar circumstance was observed in Philadelphia, in 1846.- 
Dr. Wilcocks noticed that the occupants of houses, exposed 
freely to the southerly winds, suffered much more generally than 
those living on the same street, but more or less sheltered from 
these winds.^ 

Sir Gilbert Blane, in speaking of bilious remittent fever, says : 
— "I have known a hundred yards in a road make a difference in 
the health of a ship at anchor, by her being under the lee of 
marshes in one situation, and not in another. It is difficult to 
ascertain how far the influence of vapors from woods and marshes 

^ Johnson on Trop. Climates, p. 11, p. 123. ' 

2 Am. Journ. Med. Sci., Jan., 1847. 



CAUSES.— MALARIA. 349 

extends; but there is reason to think that it is to a very small dis- 
tance. When the ships watered at Rock Fort, they found that if 
they anchored close to the shore, so as to smell the land air, the 
health of the men was affected ; but upon removing two cables' 
length, no inconvenience was perceived."^ 

The effect of a wall of dense foliage in arresting the progress 
and preventing the diffusion of malaria has often been noticed. 
A striking instance is given by Dr. Wooten, of Alabama. I 
quote from Dr. Lewis's Medical History of Alabama. "Mr. 
P. E. had negro quarters situated on the first prairie elevation 
above the low grounds of a small creek, the fourth of a mile from 
the houses. This belt of low ground frequently overflowed, 
causing water to remain in holes over its entire breadth, on the 
subsidence of the stream; but it was well shaded by a dense 
foliage, the plantation lying on the prairie in the rear of the 
cabins. In the winters of 1842 and 1843, the trees between the 
houses and creek were cleared away; and up to that time, some 
eight or ten years, the negroes living in this quarter had enjoyed 
uninterrupted health, a case of fever scarcely ever occurring. 
During the summer of 1843, the first after the forest had been 
cleared away, fever prevailed amongst the negroes with great vio- 
lence, continuing until frost. The negro quarters were after- 
wards removed to the opposite side of the creek, about the same 
distance from it, but with an intervening growth of timber, and 
no fever has occurred on the place since. "^ 

The latent period of the poison is quite indefinite ; it is some- 
times short, and sometimes long. Disease may follow its recep- 
tion into the system, in the course of a day or two, or not until 
after the lapse of several months. Illustrations of this law are 
often furnished on a large scale by armies. John Hunter gives 
an instance which occurred in Jamaica. A fine healthy regiment, 
stationed in a malarious locality, suffered severely from fever ; 
they were removed to a healthy region, and first attacks continued 
to occur for four months after the removal. Dr. Bancroft says, 
many officers and soldiers, after their return from the expedition 
to Zealand, had primary attacks of intermittents, from six to nine 
months after their arrival in England.^ Macculloch doubts the 

' Dis. of Seamen, p. 221. 2 Med. His., etc., p. 17. 

3 Bancroft's Essay, p. 241. 



350 PERIODICAL FEVER. 

entire authenticity and conclusiTeness of these reported instances 
of the action of malaria, at so long a period of time after expo- 
sure.^ 

The duration of the exposure to the poison, necessary for the 
production of the disease, is very short. 

The susceptibility of the system to the influence of malaria is 
lessened by long continued exposure, but it is not destroyed. 
Malaria itself is destroyed, and its further CToIution arrested by a 
temperature as low as the freezing point. 

1 MacoaSkxh <m. Maz^ FeTi^ p. 24. 



351 



CHAPTER V. 

VARIETIES AND FORMS. 
ARTICLE I. 

BILIOUS REMITTENT FORM. 

I HAVE already spoken of the subdivision of periodical fever 
into its three principal forms; and it is in this chapter that I find 
a suitable place for stating the grounds of this subdivision, and 
for indicating the principal features of these three leading varie- 
ties. Bilious remittent fever has now been pretty fully described ; 
and it is sufficient to say, here, that the principal point of dissem- 
blance between it and the pure intermittent form, consists in the 
continuance, in the former, of a considerable degree of febrile 
excitement, or of morbid action, during the intervals between the 
paroxysms or exacerbations of the disease. The several elements 
of a paroxysm, — the chill, the febrile reaction, and the perspira- 
tion, — are also more distinctly marked in the intermittent, than 
they are in the remittent variety; and they are repeated from day 
to day, or from period to period, with greater regularity and uni- 
formity. The remittent form is generally more inclined to run a 
determinate course, and then to cease, or to pass into the inter- 
mittent form, than the latter. The fundamental pathological 
difference between the two varieties consists, probably, in the 
existence in remittent fever, of more fixed and permanent local 
irritations, than are to be found in intennittent fever. Bilious 
remittent fever itself can hardly be said to exhibit any very uni- 
form or well marked varieties. Still, it is important to state, that 
the fever of one season and one locality frequently differs pretty 
widely from the fever of another season, or another locality; and 
similar differences may exist between the disease during one por- 
tion, or another of the same season. In this respect, periodical 
fever only partakes of the mutability to which almost all diseases, 



352 PERIODICAL FEVER. 

— and especially such as are at all endemic or epidemic in their 
character,— are subject. During certain seasons, and throughout 
certain regions, it is not only more or less violent and dangerous, 
than it is at other times, and in other places, but it assumes cer- 
tain peculiarities, more or less striking; at one time, there is a 
predominance of one set of symptoms, — at another, of another 
set. Cleghorn says, — "In July, when these fevers first break 
out, their type is commonly simple and regular; their paroxysms 
are of short duration; and after three, four, or five periods, they 
vanish of their own accord. As the season advances, the tertians 
become more dangerous and difficult, often terminating in malig- 
nant forms, especially if much rain without wind fall during the 
dog-days. About the time of the equinox, they assume a sur- 
prising variety of forms, and very often counterfeit continual 
fevers, having long redoubled paroxysms. But as the winter 
draws near, their type becomes more simple, and though they 
prove tedious and obstinate in cold weather, yet they are more 
regular and less dangerous than in the summer."^ Dr. Steward- 
son says, — "In some seasons, the remissions are very well marked, 
and the disease very manageable ; whilst in others, it is more pro- 
longed, the remissions more obscure, and the symptoms of the 
typhoid state more developed."^ 

ARTICLE II. 

CONGESTIVE FEVER. 

Sec. I. — JYames. There has been a good deal of confusion from 
the somewhat indefinite signification which has been attached to 
the term congestive fever, and from the loose manner in w^hich it 
has been applied. The qualifying prefix, congestive — is generic 
in its character; like the term typhoid, it is expressive of a patho- 
logical state, or condition, which may exist in different diseases. 
In this way, most writers speak of congestive varieties, or cases, 
of cholera, of scarlatina, of yellow fever, and so on. They mean 
simply those forms of these diseases, in which this pathological 
element, thus designated, predominates. The essential nature of 
the pathological condition itself is obscure. It is probably com- 

' Rush's Cleghorn, p. 107. ^ Amer. Jour. Med. Sci., April, 1842. 



VARIETIES AND FORMS. 353 

plex; and it may be more or less modified by its connection with 
individual diseases. In its simplest form, Ave generally under- 
stand by it, an undue accumulation of blood in the vessels — 
usually the larger ones, and especially the veins, — and the tis- 
sues of an organ, or part. But in its connection with the grave 
forms of disease, of which I have just spoken, there seems to 
enter into its composition some unknown but profound modifica- 
tion of the great function of innervation. This function is the 
seat of a sudden and violent perversion; and at the same moment, 
there is a like sudden and violent rush of the blood towards some 
one or more of the organs; or a draining off of the serum, as hap- 
pens in epidemic cholera. This congestive state generally occurs 
during the early period of the diseases with which it is associated. 
The term congestive fever is now generally made use of, in the 
Western and Southern states, to designate the pernicious or malig- 
nant form of malarious fever. I can see no objection W'hatever to 
this use and application of the term ; it is only important that its 
meaning should be determinately settled, and its application gene- 
rally agreed upon. I would never attempt to introduce a new 
name for a common disease, so long as an old and familiar one 
could be found, not positively and seriously objectionable. 

Sec. II. — Type, and mode of Attack. Congestive fever may 
belong either to the intermittent or to the remittent variety ; but to 
the former, more frequently than to the latter. It may also assume 
any of the types of periodical fever; but the quotidian and tertian 
are the most common. 

Sometimes the disease is fully developed, and clearly marked 
at the outset, — the congestive seal is set upon it during its first 
paroxysm. At other times, and this seems to be more common, 
the first paroxysm does not differ very essentially from an ordinary 
attack of simple intermittent. Dr. Charles Parry, who has writ- 
ten a short and fragmentary, but most excellent paper upon the 
disease as it occurs in Indiana, says, — " In the majority of cases, 
the symptoms of the first paroxysm are such as occur in an ordi- 
nary intermittent attack. One main peculiarity is an expression 
of intense apprehension, or terror, without experiencing it. Per- 
haps the face is paler, or more livid, than in common cases. * * 
The first paroxysm attracts so little attention, that after it is over, 
the patient meeting a physician, or friend, says, that he feels as if 
23 



354 PERIODICAL FEVER.— CONGESTIVE FORM. 

he were about to be sick, not that he has been sick. The second 
paroxysm is always severe, not so much in the violence of the 
rigors, as in the extreme coldness, and in the approaching death- 
like hue of the face and extremities."^ 

Sec. III. — Varieties ; comatose. Congestive fever occurs under 
several well-marked and pretty distinct varieties, depending, pro- 
bablv, upon the predominance of certain elements in its complex 
pathologv. Torti divided the disease into seven varieties, to wit, 
— 1. Choleric, or dysenteric; — .2. Subcruenta, or atrabiliaris ; — 
3. Cardiac; — 4. Diaphoretic; — 5. Syncopalis; — 6. Algid; — 7. 
Lethargic. Alibert makes no less than twenty varieties, elevating 
to this distinction every case marked by any peculiarity, acci- 
dental and unimportant as it may happen to be. The most com- 
mon and important forms are the comatose, the delirious, the algid, 
and the gastric, or gastro-enteric. It is necessary, in order to get 
a distinct and adequate idea of the disease, to give separate de- 
scriptions of these principal varieties. To aid me in doing this, 
I shall transfer to my pages a series of graphic delineations from 
the capital work of Maillot. 

"The name of the comatose variety," — he says, — "indicates 
its essential character. The coma varies from simple stupor to 
the most profound earns. The pulse is full, large, without hard- 
ness, ordinarily a little accelerated, sometimes slower than natu- 
ral. The patient lies upon his back, the limbs as it were para- 
lyzed ; when the coma is not carried to its highest degree, if the 
skin is pinched, he utters a feeble and plaintive cry; there is 
often trismus ; still liquids can generally be swallowed, although 
with considerable difficulty; sometimes, however, they are re- 
jected, either by a sudden and convulsive movement, or by a tran- 
quil and prolonged expulsion. In some rare cases, instead of the 
usual resolution of the limbs, there are epileptiform movements, 
frothing at the mouth, and grinding of the teeth, truly frightful 
from their noise and rapidity. It is during the second paroxysm, 
that the coma shows itself, in most cases nothing having occurred 
in the first, indicative of its coming. If anything may foreshadow 
its appearance, it is a certain slowness of speech, during the pre- 
ceding apyrexia. But this indication is often fallacious, and its 

1 Amer. Jour. 3IecL Sci., July, 1 843. 



VARIETIES AND FORMS. 355 

absence is no guarantee that the following paroxysm will not be 
comatose. Sometimes a case is comatose from the beginning ; at 
others, it suddenly becomes so, after a certain number of parox- 
ysms, which had not affected the brain more than is usual in 
simple intermittents. Sometimes, the coma reaches its highest 
degree suddenly, as by a single bound; at other times, and this 
is more common, the eye may follow the progress of its develop- 
ment. In the latter case, the physiognomy of the patient assumes 
that expression of stupor characteristic of comatose affections, and 
so striking in these ; his replies are slow and unfinished ; the eye- 
lids grow heavy, and close. In certain cases, the coma is pre- 
ceded by delirium. 

"After a period which it is impossible to determine beforehand, 
and which varies with a multitude of circumstances, if death is 
not occasioned by the violent cerebral congestion, a general sw^eat 
breaks out upon the surface, the patient executes some automatic 
movements, the eyelids are elevated, the e3'es remain fixed and 
widely open, he remains a long time unconscious of what passes 
about him, and it is now, especially, that his look has that air of 
astonishment, which I have never seen so strongly marked in any 
other affection. He recovers by degrees the use of his senses; 
sight, hearing, and speech, return successively. Finally, all the 
functions resume their natural play, and, in many cases, after the 
paroxysm, especially if blood-letting has been practised, there 
does not remain even headache. 

*'This variety is perhaps the most common. Most of the cases 
reported by Bailly at Rome belonged to it, and I have met with it 
more frequently than with any other form in Corsica, and Africa. 
It may be accompanied by visceral congestions, or irritations, in 
the chest, or abdomen; but these complications are accidental." 

Sec. IV. — Delirious Variety. When, during the second stage of 
a paroxysm, the headache becomes very severe, there is reason to 
apprehend the occurrence of delirium, especially, if during the pre- 
ceding intermissions this symptom has not entirely disappeared. 
The pulse is hard and accelerated ; the skin hotter and drier, than 
in the comatose form ; the eyes are brilliant, the conjunctiva in- 
jected, and the face red and animated; the patient cries, sings, 
and endeavors to escape ; the carotids and temporal arteries beat 
violently. This state of excitement commonly continues for 





356 PEiLIODICAL FEViaL-— CaWCEsriWJK FO] 

seTeral bours ; and l^en it is weA miaisaaal to see 

liie deHrinin, so tkat, h» ia- as Ite spm^oms aie 

paroxysm inayefiMlBiiiftiliieowHSE*^*^^^*"™'^'**!^ 

phenomena «jf Hae *w© s^aigES cf an 

quently occurs suddfinly, waillnMlt Ae 

is destroyed 1) J 2 : it't 5 nock. Wibaa a 

the skin becomes _-;:: i:-^~^ sweaty^liej 

the delirium gradually ceases- Haae is sone lenaimg kead- 

ache, more frequently than in l3ae conaiiwe SmmL. Hms variety is 

also Tery common, ferrous wsd nmJMip pcEBOBS^ saljedtJo : r 

pressing passions, are strongly pmeffiipoBBd to it; itisQiibem seen l. : ; 

in stout and robiii ■ : f a ^bBOB^fy m s a^gvd isai^aiiie 4eB^r : . • 

Mient. I have ne" 7; :t7- in i&e sam£ pasxoLytaM. eona pnDc r : r 

lieHrium. 

Ssc. T. — ^IgU VkaMg. ^^%>d iswor is mat geneidO^, as 1 ; : 

been said, a mere pnoSo^aitiDBL of lilie coM £iage <if a penonrs ii 

I hare iz: t' : 7 r: '^ ;::::_;-: r *:.'' ■ '71^ lifine is ]bflt«r 7 7 :. 

fiit-eset^: 7^.. la Ite inat s: : r t 

of a simple paror; :>fll fflf all proj' : • 

tion ' : 1 7 : ' \ li aiminunon ; - ."^ "fa fiacfz ; 7 

■wLi.-: ... „._._ ;7~erthccnMi5 ', 'rren'«rl7;. 
the skin is icy. J&t i 



to be open amd friraJllL. "lie pabe 

appears; the extremiti^ ^ fi«e, : : 

sirely and raridly cold: 'fc 'aWr:i_ 7 

degree of ^:.: :_. : : t : : .7 

"whateTtr z::" . 7 ::. : ; : :„ 

becomes r ' ~~ „ . : :._.:: 

pai:7 luced to drin£ : zuently : 

by 2'cg -.:_.:-;:- : the lips : t '..r'r':. : 

Toice br: 1: 7 :. _. - action c: t : 77.7 

appreciable only by : ; . : . . 7 minci is - : . 1 

the patient may seem Kj ~:_ - 7":: 'zi: ":/7 : 

cially when it has succeei7 _ ■ ; ., , . 7 / : 7 

is mthout mobility, the most ats: . _ ■ 7 

his countenance: :": f r- ^ -::-:: :, .: ^ ■ _' : / 

ings and choleric _ . . . _. : . 7 . _.; 7 ^ . , 7 _ ; . _. . ; :.._-_ 



VARIETIES AND FORMS. 357 

the eyes become sunken and glassy, and are surrounded by a blue 
circle ; and it is only when the respiration is carried on through 
the open mouth that the tongue becomes dry and dark colored. 
The march of this variety is very insidious ; there is no one per- 
haps, "whose vigilance has not been deceived by it. If one is not 
familiar with this state of things, the kind of calm which follows 
the febrile excitement may easily be mistaken for a great ameliora- 
tion, attributable perhaps to sanguineous depletions, and the mis- 
take is revealed only by the sudden and unlooked for death of the 
patient. 

Bailly notices particularly the tranquil expression of the counte- 
nance in these cases. "I have already mentioned," — he says, — 
" that in algid fevers, the patients pass from life to death, without 
our being able to foresee this event ; we can hardly believe them to be 
sick even, either during the intermissions, or the paroxysms, espe- 
cially in the early period of the latter." In the reflections which 
follow the report of his thirty-seventh case, he says: — "In this 
instance, especially, the color of the face w^as natural ; its expres- 
sion was that of repose, of tranquillity; only the muscles w^ere a 
little tightened upon the bones of the face, but not like those of a 
phthisical patient, or of a person dying from acute gastritis ; it was 
rather the look of a man in full health w-ho rests after excessive 
fatigue. Indeed if this man had not been pointed out to me as 
one attacked w^ith algid fever, I should not have paused to notice 
him, near as he w^as to the termination of his existence ; and when 
the paroxysm came on, his countenance, without becoming any 
more alarming in its expression, approached that of a person just 
sinking into sleep. Nothing could be more striking than the con- 
trast between this immobile face and the pain which he alleged 
to exist in the abdomen. It seemed as if the torpor in w^hich he 
was plunged had destroyed all the sympathies which usually exist 
between our organs, and as if the suffering abdomen had no power 
to act upon the physiognomy with which it was no longer in rela- 
tion."^ 

Whenever to a reaction, more or less decided, there suddenly 
succeeds feebleness of the pulse, with paleness of the tongue, 
and colorless lips, there should be no hesitation in regard to the 
case, — it is one of algid fever. Temporizing here is death. 

' Traite des Fievres Intermittentes. Par E. M. Bailly, p. 235. 



358 PERIODICAL FETEK.— CONGESTITE FORM. 

When the termination is to be favorable, the pulse becomes more 
distinct; the ^km resumes its natural heat; and there follows 
sometimes, thongh rarely, an irritation of the brain, or digestive 
oigans, requiring smguiQeons depletion. The coldness dissipated, 
the patient enters at once into full convalescence, as he does after 
a comatose or delirious paroxysm. I have never seen the pheno- 
mena constituting algid fever proceeding by distinct paroxysms ; 
they hare hardly presented any appreciable remissions ; once 
establi^ed, they march steadily towards death, unless they are 
airesled."* The pnlse. Dr. Charles Parry says, even from the 
beginning of the second paroxysm, is rapid, small, and thready ; 
sometimes hard and wiry, and sometimes irregular and intermit- 
ting. The skin is of a livid hue, and of a marble coldness ; and 
it is coTered from head to foot with a cold, clammy, sticky sweat ; 
in sxmie instances, this perspiration is confined to the face and 
neck. The hands are shrivelled, hke a washerwoman's, and the 
patient begs for cold drinks, and to be fanned.^ 

According to Maillot, the three preceding varieties constitute 
the immense majority of cases of pernicious intermittents. 

Sec. VI. — Gustro- enteric Variety. This form of cons^estive 
fever seems to be pretty common in our western and southern 

Dr. Charles Parry, in his description of it, says, — "The vomit- 
ing and purging are almost incessant ; the discharges are often 
mixed -with blood, but not with bile. They have the appearance 
of water, in which a large portion of recently killed beef has been 
washed. Some&nes, however, the proportion of blood is much 
greater, at times amounting almost to clear blood ; and from three 
to fire, or even twelve, ounces at a discharge, with intervals of 
from ten to forty minntes. The discharges have but little odor, 
and there is but little abdominal pain, or tenderness ; though the 
patient complains of a sense of weight and burninsr ^^^t in the 
stomach. * *" The thirst is most intense. The constant cry 
is for cold drinks, cold ice water ; and a very common exclamation 
is, 'O, that I conld lie in the river!' — 'If I could only have a 
stream of cold water runninor throuo-h me!' '" 

I add the following, from Dr. Parry's general description. 

» Tiaiie des iiSTies InfeEniiit^ate& Par F. G. Maiiiot, pp. 2S-36. 
* Am^. Joar. Med. Sq , Jolr, 1843, a ibid. 



VARIETIES AND FORMS. 359 

'*The respiration,'' — he says, — "is often very peculiar. It con- 
sists of a deep drawn double inspiration, or double sigh, with one 
expiration. This double breathing is seen in perhaps more than 
two-thirds of the cases; it is a fatal symptom. It is seen very 
early in the second paroxysm, generally at the beginning, and 
continues to its close, either in the agony of death, or to the febrile 
reaction. 

" Restlessness is very great, the patient constantly tossing about 
from one side of the bed to the other, throwing about his arms 
and legs ; frequently endeavoring to get out of bed, and walking 
across the room, if permitted, only an hour or tw^o before death. 
I have seen persons get out of bed, walk across the room, and 
stand in the doorway, hours after it was impossible to detect any 
pulse at the wrist, though the carotids could be felt plainly. Such 
is the intense desire of patients to get cold air, that they frequently 
express themselves determined to have it, at all hazards ; and, 
indeed, it frequently happens, even when nearly all the symptoms 
just enumerated are present, that the patient does not think there 
is much the matter with him, and wonders w^hy he is kept in bed, 
and not suffered to go out. 

" The usual length of the fatal paroxysm is from three to six 
hourB, though it is longer in some cases ; — the moribund symp- 
toms increasing, the pulse becoming more and more frequent, 
feeble, irregular, thready, and fluttering ; the respiration prolonged 
and sighing; the skin cold and shrivelled, and covered with large 
drops of clammy perspiration."^ 

It is proper to mention that the preceding varieties may be 
more or less mixed up with each other, sometimes one of them 
preponderating, and sometimes another. It is hardly necessary 
to take any separate notice of the minor varieties, — the cardiac, 
the icteric, the syncopalic, and so on. 

ARTICLE III. 

INTERMITTENT FEVER. 

The principal points of difference, betw^een the simple inter- 
mittent and the bilious remittent forms of periodical fever, have 

• Amer. Jour. Med. Sci., July, 1843. 



360 PERIODICAL FEVER— mXERMITTENT FORM. 

already been indicated. It only remains for me here to give a 
short general description of the former variety of the disease. 

The paroxysm of a regular and simple intermittent commences 
with the rigor, or chill. This is usually severe and strongly 
marked. The patient has an intense feeling of coldness; his 
teeth chatter, and his whole body shivers with cold. The skin 
is pale and shrivelled, with a dark bluish or purplish tinge on the 
tip of the nose, the lips, and the extremities, and it is cold to the 
touch; the features are pinched and shrunken; the expression of 
the face is languid, listless, and uneasy; there are frequent gaping 
and yawning; a general feeling of weariness and fatigue, pains in 
the head, back, and limbs ; sighing respiration, oppression of the 
praecordia : a small and frequent pulse ; and the mind is feeble 
and depressed. Such are the ordinary and more obvious phe- 
nomena constitutinsr the cold fit. The urine is 2:enerally abundant 
and limpid. 

After a period of time, varying from fifteen or twenty minutes 
to three or four hours, the average length being an hour or so, 
the first stage passes gradually into the second. The sensation 
of coldness yields to a feeling of morbid heat; the skin is full and 
injected, and is hot to the touch ; the face loses its languid ex- 
pression, and becomes animated and flushed; the prscOTdial 
oppression is sometimes removed or diminished, but not always ; 
there are less languor and depression; the local pains, instead of 
diminishing, are increased in severity; the pulse becomes full and 
strong; there is increased thirst; and the urine is now scanty and 
high colored. 

This second or hot stage continues from one to fifteen or eigh- 
teen hours, and then gives way to the third, or sweating stage, 
which completes the paroxysm. As the surface becomes moist, 
the febrile perturbation subsides; — the pulse is slower and softer; 
the expression of the face tranquil; the local pains, and the other 
uneasy sensations disappear; the urine deposits a reddish sedi- 
ment, and there is a general and delightful feeling of relief and 
of restoration to health. 

The period between the termination of this and the commence- 
ment of the next paroxysm constitutes the intermission. In many 
cases, where the disease is quite simple, and where there are pro- 
bably no considerable local irritations or congestions, this apyrexial 
period seems to be one of entire freedom from disease. The strength, 



VARIETIES AND FORMS. 361 

the appetite, and the cheerfulness of the patient are restored ; all 
his functions, animal and organic, seem to have resumed their 
healthy activity. In other instances, however, there are still 
remaining, throughout the entire period of intermission, evidences 
more or less obvious and serious, of a disordered state of the 
system. 

The entire duration of the paroxysm, as well as that of its 
several stages, varies very greatly in different cases. It ranges 
from a few hours to eighteen or twenty. 



362 



CHAPTER VI. 

DURATION AND MARCH. 

Sec. I. — Duration. The average duration of the common form 
of remittent fever seems to be about two weeks, perhaps a very 
little longer. Of eleven cases, treated in the Pennsylvania Hos- 
pital, by Dr. Gerhard, the mean duration was fourteen days and 
a half; of fifty-four cases, treated in the same institution, and re- 
ported by Dr. Stewardson, the mean duration was about fifteen 
days. 

The duration of the other varieties is so various and indefinite, 
and so much influenced by circumstances, that it is not easy to 
establish any positive averages. Congestive fever terminates 
speedily, in most cases, either in recovery or death. Dr. Charles 
Parry says, — "The general duration of this disease is from six to 
nine days, in recovering so as to walk about; in fatal cases, from 
two to three days, death usually occurring in the second or third 
paroxysms, hardly ever in the first. "^ 

The duration of the simple intermittent form is altogether in- 
definite. It may consist of only one or two paroxysms ; or it may 
be continued, with more or less regularity, for several weeks, and 
even for several months. 

Sec. II. — March. The types of periodical fever have been 
already sufficiently treated of in the chapter on the symptoms of 
the disease. The march of the fever differs considerably in the 
different forms of the disease. The progress of remittent fever is 
generally pretty regular, — the disease gradually increasing in 
severity, until it reaches its height, or acme, and then passing 
into convalescence. Cleghorn seems to have studied this subject 
with great care, and he makes the following observations in regard 
to it. " As the fever advances to its height, the coldness and 

^ Amer, Jour. Med, Sci., July, 1843. 



DURATION AND MARCH. 363 

shivering which usher in the paroxysms become less, or entirely 
imperceptible ; in which case, a cholera morbus, or acute pains 
in the back or limbs, supply their place. In the mean time, the 
paroxysms themselves become longer, and bring on more formi- 
dable symptoms, such as headaches, raving, sopors, apoplectic 
fits, bleeding at the nose, cough, difficulty of breathing, palpitation 
of the heart, irregularity of the pulse, sickness and anxiety, pain 
about the upper orifice of the stomach, and so on. Besides, it 
often happens, during the second, third, fourth, or fifth period, 
that the tertian becomes double, though at first it was simple ; or 
if it was double from the beginning, the weaker fit continues 
without any intermission, till the stronger comes on, and both 
being blended together, the disease puts on the appearance of a 
semi-tertian, having one very long fit, with a short interval every 
forty-eight hours. It must likewise be observed, that in the pro- 
gress of the fever, the regular order of the periods is frequently 
disturbed by the paroxysms changing their hour of invasion, and 
attacking unawares, without any previous cold. After this man- 
ner, these proteiform distempers continue to vary their shape in 
every period, and to produce longer, more severe, or more fre- 
quent paroxysms till they arrive at their height; about which time 
the fits and intervals are often so confused, that they are scarcely 
to be distinguished: nevertheless, if death be not speedily the 
consequence of this confusion, they commonly again put on a 
more simple or regular form, and, after one or more slight parox- 
ysms, go away of their own accord. Those fevers which come 
to their height in the third period, terminate in the fourth or fifth 
period ; those which come to their height in the fourth period, ter- 
minate in the fifth or sixth ; and those which come to their height 
in the fifth period, terminate in the sixth or seventh. When the 
most vehement paroxysms happen on the odd days, the crises w^ill 
be on the odd days : when they happen on the even days, the 
great changes of the distemper will likewise be on the even days. 
If the fever increases to the seventh period, it probably will not 
cease before the ninth; but it rarely happens that remitting tertians 
run out to so great a length. Yet I have seen, every year, a few 
of the continual kind, which began with great mildness, and in- 
creasing by slow degrees, broke out violently in the third or fourth 
week, and soon after ended in intermittents ; though some of them 
have continued without any considerable interval for six or seven 



364 • PERIODICAL FEVER. 

weeks. But it is much more common to meet with tertians, which 
set out furiously, with severe subintrant double paroxysms; so 
that for some days they have little or no interval. On the third 
or fifth day a profuse sweat commonly brings on an intermission ; 
and afterwards the disease assumes the type of a double intermit- 
ting tertian, or of a semi-tertian. Such fevers I have frequently 
observed to terminate spontaneously on the seventh, ninth, and 
eleventh days ; and, for the most part, they are less to be feared 
than those which begin deceitfully in the shape of a slight double 
or simple tertian. For however mild and insignificant these in- 
termittents may at first seem to be, we are never to trust appear- 
ances, till they have performed three or four revolutions."^ 

The progress of the malignant form of the disease is more 
irregular and uncertain. 

Senac thus speaks of the sudden and great changes so striking 
in this last variety. " It may be thought singular in these dis- 
eases, that sometimes from so slight a beginning, the danger should 
become so urgent and threatening, in the course of a few days. 
But it is a problem no less difficult to solve, how a cause which 
so disorders the brain, and so oppresses the lungs, can, of its own 
accord, give the system a temporary respite, or cease for a time 
to act. Thus, after the third or fourth day, the action of this 
cause is suspended, and for a day or more the patients seem free 
from disease. Other maladies do not pursue such a course; in 
them the aflfected parts recover only by degrees ; and after they 
have recovered, or appear to have recovered in the space of a day 
or two, the life of the patient is seldom brought into danger 
again by a sudden return of the disease ; at least this is not gene- 
rally the case, as it is in malignant intermittents. * * * Hence it 
appears that these terrible symptoms may arise from some wan- 
dering stimulus, which flies off and returns, or acts and lies dor- 
mant, alternately; and that they are sometimes more alarming in 
appearance, than dangerous in reality."^ Bailly says, — " This 
sudden transition from a state of imminent danger to apparent 
safety k especially characteristic of comatose intermittents. In 
the other varieties of pernicious fever, there is not so striking a 
difference between the different stages of a paroxysm. * * * A 
finger compresses the brain, — the patient sleeps; if the pressure 

' Rush's Cleghorn, p. 95, et seq. 2 Caldweirs Senac, p. 118. 



CRITICAL DAYS.— RELAPSES —SEQUELAE. 365 

is light, everything returns promptly to its natural condition; if 
the pressure is strong, it kills on the spot."^ 

Sec. III. — Critical Bays. It is the proper place here to say a 
word or two about the existence of what have been called critical 
days, — days upon which, more than upon others, the disease has 
a tendency to terminate, either in recovery, or death. There is 
no doubt whatever that the old doctrine upon this subject is the 
true one, and the disputes which have arisen about it have origi- 
nated in the circumstance that physicians have endeavored to 
apply it to the family of continued fevers, a class of diseases in re- 
gard to which it utterly fails. It follows almost necessarily, that 
a disease, marked as periodical fever frequently is, by a regular 
tertian revolution, should be liable to particular changes, either 
for better or for worse, on particular days ; and this is the whole 
substance of the doctrine of critical days. 

Sec. IV. — Relapses. Periodical fever, more than any other form 
of acute disease, is liable to return, and to repeat itself, again and 
again, in the same subject. When the malarious poison has been 
once received into the system, the action of slight occasional 
causes will often continue, for a long time, to bring back the dis- 
ease. 

Dr. Charles Parry says of congestive fever, — "Once having had 
an attack does not exclude the possibility of having another the 
same season, although a second attack is rare. I had one patient 
who had two attacks one season ; and I had one patient who had 
an attack in three successive summers."^ 

Sec. V. — Sequelce. Periodical fever, especially if it has been 
often repeated, or long continued, very frequently leaves behind it 
serious and profound alterations of some of the organs, or more or 
less grave disturbances of their functions. The principal of these 
I shall here enumerate. The first to be mentioned consist of va- 
rious chronic alterations of the liver and spleen, especially the 
latter. These organs become enlarged, indurated, or both ; and 
their intimate structure, in many instances, variously changed. 
From the time of Hippocrates to the present day, the frequency 
of these chronic, organic alterations has attracted the notice of all 

' Traite, etc., p. 171. 2 Am. Jour, of Med. Sci., July, 1843. 



366 PERIODICAL FEVER. 

observers. ^Mien they become inveterate and extensive, from 
long exposure to the malarious poison, and from repeated attacks 
of fever, they generally entail upon the patient gradually increas- 
ing debility, dropsical accumulations, a broken down constitution, 
and finally death. In many instances, however, it is surprising 
to what an extent, and for how long a period, the system will 
bear up against these inroads. " I have often seen these sub- 
jects," — says Bailly, — '• arriving at the hospital in Rome, with 
the abdomen hard as a stone, the spleen occupying the whole an- 
terior part of the cavity. A few intermittent paroxysms consti- 
tuting the onlv disease which brought them to the hospital, they 
were treated like the other patients; the paroxysms were arrested 
by quinine, and at the end of two or three weeks, they departed 
to resume their occupations, cured of the fever, but with the ab- 
domen as hard as ever." Maillot says that he has often noticed, 
amongst the shepherds of Corsica, stout and robust men, engaged 
in rough out-door occupations, with the abdomen enormously dis- 
tended in consequence of these alterations.^ 

The notion has been extensively prevalent, that these visceral 
obstructions are the result, not of the disease itself, but of the bark 
and its preparations, which are given for its cure. It is hardly 
necessary for me to say that there is no foundation whatever for 
this opinion. 

The dropsical effusions, and especially the ascites, which so 
frequently accompany the latter stages of these cases, are, for the 
most part, the result, simply, of the changes in the state of the 
liver and spleen. 

In hot climates and seasons, long continued cases of periodical 
fever are pretty frequently followed by chronic dysentery and diar- 
rhoea. Maillot says, that these consecutive affections are almost 
constantly without fever; there is little or no pain in the bowels: 
the discharges are serous, mucous, or sanguinolent, and generally 
abundant and frequent, but sometimes scanty. There is rapid 
emaciation; the skin is of an earthy hue, dry and furfuraceous. 
Of thirty cases, occurring in the French military hospital in Al- 
giers, fourteen terminated fatally.^ 

Dr. Finley, in a paper on the autumnal fever of Georgia, says : 
— "A severe attack of the disease always leaves the system very 

' Traite des Fievxes Intermittentes. p. 246. 2 Ibid... p. 234. 



SEQUELS. 3(37 

much deranged. All the secretions are impaired ; the skin is dry 
and harsh ; the biliary secretion alternately vitiated and defective ; 
the bowels constipated."^ 

Another pretty common consequence of this disease consists in 
different disturbances and perversions of the nervous system. 
Amongst these, are neuralgic pains; headache; muscular weak- 
ness; partial and incomplete paralysis, usually of the lower 
limbs; and impaired activity, or derangement, of the mind. 
Senac says, in speaking of the headache, — "patients sometimes 
declare that the head feels as if it were cleft asunder in the mid- 
dle." Dr. Mosely says : — "Imbecility of mind, as well as of body, 
is a common consequence of long and obstinate disorders in hot 
climates ; and I have frequently observed that the mind has been 
greatly impaired after irregular and harassing intermittents; and 
sometimes a temporary insanity has ensued. This must have 
been also observed by others ; but as far as I know, no person 
except Sydenham, who was the first that noticed it, has men- 
tioned it as occurring in practice. He says he has often found, 
when the patients had been extremely debilitated by long con- 
tinuance of the disease, the doubling of the fits, and repeated 
evacuations, that they have been seized with a madness, when 
they began to recover, which went off proportionally as they 
gathered strength ; but, that, sometimes, from injudicious evacua- 
tions, only, it has degenerated into a miserable kind of folly for 
life."^ Maillot mentions amongst the effects of the disease, no- 
ticed amongst the French soldiers in Africa, extreme debility 
during convalescence, especially in the hot season; and trembling 
of the muscles, like slight chorea, or like the paralysis of the 
insane. He thinks that neither the type of the fever, nor the in- 
tensity of the local irritations, has much influence in the produc- 
tion of these effects.^ Macculloch enumerates a great variety of 
nervous disturbances and perversions, the result of repeated 
attacks of marsh fever. 

Another common consequence of long-continued periodical 
fever, or of the chronic lesions to which it gives rise, is an anemic 
condition of the system. The blood loses its healthy proportion 
of globules; the gums, lips, and tongue lose their fresh color; 
and the skin is sallow and pale. 

^ West. ]Med. and Phys. Joum., vol. iii. p, 179. 

2 Mosely on Trop. Dis., p. ISO. 3 Maillot on Inter., p. 250. 



368 



CHAPTER VII. 

MORTALITY AND PROGNOSIS. 

The danger attending periodical fever depends very much 
upon the form which the disease assumes. The purely inter- 
mittent and benign variety is never fatal, without some accidental 
complication. It often entails upon its subjects chronic visceral 
alterations, which impair the vigor of the system, and w^hich often 
shorten life, but it is never directly and immediately fatal. The 
ordinary remittent form is more grave in its character, but still in 
a very large proportion of instances, it terminates favorably. Of 
sixty-three cases of periodical fever, admitted to the Pennsylvania 
Hospital, in 1838, 1839, and 1840, six terminated fatally; but 
three of these belonged to the congestive form, and w^ere received 
only a short time before death ; and in one other case, the disease 
had been greatly aggravated by improper treatment.^ Dr. Wil- 
cocks treated one hundred and seventy-one cases of remittent 
and intermittent fever, in Philadelphia, in 1846, and they all re- 
covered. He does not state the proportion of cases of the two 
forms. 

At the hospital of Montlue], of thirteen hundred and fifty-two 
cases, treated between June, 1822, and December, 1826, one 
hundred and thirteen terminated fatally. At the miliary hospital 
of Bona, in Africa, in twenty-two thousand, three hundred and 
thirty admissions between April, 1832, and March, 1835, there 
were two thousand five hundred and thirteen deaths, nearly one 
in nine.^ 

Other things being equal, and, as a general rule, the gravity and 
fatality of periodical fever increase as we approach the tropics. 
"Thus," say MM. Fournier and Begin, "if we examine the en- 
demic diseases of the principal malarious countries, we shall see 
in Holland, intermittent fevers attacking great numbers of sub- 

' Am. Journ. of Med. Sci., April, 1842. 
2 Traite, etc. Par F. C. Maillot, p. 276. 



MORTALITY AND PROGNOSIS. 369 

jects, but generally following a slow march, and giving the phy- 
sician sufficient time to combat them. In Hungary, these fevers 
are more frequently remittent, and complicated with dysentery. 
The fevers of Italy, in the neighborhood of the Pontine marshes, 
have short intermissions, and are frequently complicated with 
ataxic phenomena."^ 

In regard to congestive fever. Maillot makes the following in- 
teresting observations and statements. "I do not know," — he 
says, — "how the opinion has established itself, that pernicious 
intermittents are readily curable, and that art is almost certain to 
triumph over them. But, ever since Lautter said that in these 
diseases the physician is the arbiter of life and death, writers 
have spoken very lightly of the prognosis of these terrible affec- 
tions; they have proclaimed their treatment as the triumph of 
medicine. Certainly, it is a beautiful thing to snatch from an 
imminent death, to rescue almost from the tomb, a man stricken 
with a pernicious paroxysm; the danger was so urgent, that one 
has hardly indulged a hope of his patient's recovery, when he is 
already cured -y but, deceived by the eclat of similar successes, 
we have been carried aw^ay by our enthusiasm, and have refused 
to believe in the possibility of reverses, for it has been almost 
alleged that we had reached mathematical certainty in the treat- 
ment of these diseases. But, to this enthusiasm, in w^hich w^e 
ourselves for a long time participated ; to these sanguine antici- 
pations which we should still rejoice to indulge, let us oppose the 
rigorous impartiality of positive, statistical results. In eight 
hundred and eighty-six cases of pernicious fever, observed in 
1818, and 1819, at the hospitals of the Holy Spirit, and Saint 
John in Lateran, at Rome, there were five hundred and forty-five 
recoveries, and three hundred and forty-one deaths, — one death 
in two and a quarter. In five hundred and eighty-one cases of 
periodical fever, observed by M. Nepple, fourteen belonged to the 
pernicious form ; six of these terminated fatally. Antonini and 
Monard, in thirty-nine comatose, or apoplectic cases, had nine 
deaths; in eighty-six encephalitic cases, they had only eight 
deaths, — unquestionably the most favorable result on record, if 
they include in this category only cases of the delirious variety. 
The following is the result of my own experience. I have notes 

' Diet, des Sci. Med., art. Marais. 

24 



370 PERIODICAL FEVER. 

of one hundred and eighty-six cases, belonging to the comatose, 
delirious, and algid varieties, occurring between the first of June, 
1834, and the first of March, 1835, thirty-eight of which,— about 
one-fifth, — terminated fatally. Seventy-seven comatose cases fur- 
nished fourteen deaths, — one in 51; sixty-one delirious cases fur- 
nished twelve deaths,— one in 5 ; and forty-eight algid cases fur- 
nished twelve deaths,— one in 4. The mortality varied with the 
type, in the following manner. Sixty cases of the quotidian type 
furnished fifteen deaths,— one in 4 ;— thirty of these were of the 
comatose form, and gave six deaths, — one in 5; twenty-one were 
of the delirious form, and gave five deaths, one in 4 ; and nine 
w^ere of the algid form, and gave two deaths, — one in 4|. 
Twenty-seven cases of the tertian type furnished six deaths, — 
one in 6, nearly; — nine of these were of the comatose form, and 
gave two deaths, — one in 4J- ; fourteen were of the delirious form, 
and gave three deaths, — one in 5, nearly; four ^vere of the algid 
form, and gave one death, — one in 4. Ninety-nine cases of the 
remittent and pseudo-continued type, furnished nineteen deaths, — 
one in 5, nearly ; — thirty-eight of these were of the comatose 
form, and gave six deaths,- — one in 6, nearly ; twenty-six were 
of the delirious form, and gave four deaths, — one in 6, nearly; 
thirty-five were of the algid form, and gave nine deaths, — one 
in 4. 

"Such is the mean rate of mortality that has attended pernicious 
fevers at Bona. In localities where the malarious poison is less 
powerful, it is probable that more favorable results may be looked 
for ; but, otherwise, I have reason to believe, from the researches 
which I have made, that proportions much more encouraging than 
those just indicated have never been obtained, unless it may have 
been accidentally. 

"If now we endeavor to ascertain the modes in which death 
takes place in periodical fever, we shall find that in the acute 
forms, the patient is either carried off suddenly, during a parox- 
ysm ; or that the paroxysms are prolonged and run into each other, 
the visceral congestions becoming fixed and being followed by 
inflammation, and complicated, frequently wdth a typhoid condi- 
tion. When death does not happen in either of the foregoing 
modes; when relapses have followed each other in rapid succes- 
sion; especially when the disease has been neglected, and the 
irritations feebly combated, there then supervene chronic afifec- 



MORTALITY AND PROGNOSIS. 37X 

tions of the digestive tube, engorgements of the abdominal vis- 
cera, intractable diarrhoeas, dropsical effusions, etc. 

"Amongst three thousand seven hundred and sixty-five patients, 
received into the military hospitals of Bona, in the space of four- 
teen months, there were one hundred and thirty-five deaths, 
occurring in the following modes. Fifteen hundred and eighty- 
two cases of the quotidian type furnished forty deaths, — one in 
40, nearly; of these patients, eight died in a delirious paroxysm; 
eight, in a comatose paroxysm; three, in an algid paroxysm; one, 
with jaundice; five, in a typhoid condition; thirteen, with chronic 
diarrhaa or dysentery; one, with acute dysentery; and one, ane- 
mic. Seven hundred and thirty cases of the tertian type furnished 
twelve deaths, — one in 61, nearly; of these patients, three died 
in a delirious paroxysm; two, in a comatose paroxysm; one, in 
an algid paroxysm; three, with chronic diarrhoea or dysentery; 
and one each, with chronic bronchitis, chronic pneumonia, and 
marasmus. The quartan type furnished no death. One double 
tertian had a fatal issue, after six weeks' duration. Seventj^-nine 
cases of the remittent type furnished two deaths, — one in a deliri- 
ous and one in a comatose paroxysm. Thirteen hundred and 
thirty-two cases of a continued or pseudo continued type furnished 
eighty deaths, — one in 16J-, nearly ; of these patients, five died 
in a delirious paroxysm; seven, in a comatose paroxysm; ten, in 
an algid paroxysm; thirty-one, with chronic diarrhoea or dysen- 
tery ; three, with acute dysentery; three, with typhoid affections; 
three, with chronic pneumonia ; six, with acute follicular colitis ; 
two, with chronic bronchitis ; two, w^ith chronic affections of the 
heart ; and one each, with acute gastro- colitis, encephalitis, ence- 
phalic irritation followed by paralysis, apoplexy, acute bronchitis, 
acute carditis, and marasmus. 

" To sum up these details, death took place during the parox- 
ysm, in fifty-one cases ; in a typhoid condition, in eight cases; from 
diseases such as occur in non-malarious regions, in fifteen cases; 
from chronic affections, in sixty-one cases, forty-seven of which 
were chronic diarrhoeas or dysenteries."^ 

In another place. Maillot says, — "The prognosis in pernicious 
fever is always very grave. The principal varieties, — the deliri- 
ous, the comatose, and the algid, — give nearly the same mortality. 

1 Traite des Fievrcs Intermittentes. Par F. G. Maillot, p. 277, et seq. 



372 PERIODICAL FEVER. 

When, notwithstanding large sanguineous depletions, the coma 
continues profound, and the pulse remains strong and full, although 
the patient may be bathed in sweat, we have reason to fear a fatal 
issue. Death may be equally apprehended, if the persistence of 
the coma is accompanied by a rapid, feeble, small and vibrating 
pulse. There are comatose cases where the trismus is so strong 
that the patient is unable to swallow ; or where, on the other hand, 
the rectum w^ill not retain any injection; — the prognosis is here 
very unfavorable ; there are no means of administering the sul- 
phate of quinine, but by the skin. The delirious variety isolates 
itself, less frequently than the comatose, in the nervous system ; 
it is more frequently associated with symptoms of acute abdo- 
minal inflammation; if with this there is vomiting, so that the 
febrifuges are rejected, the danger is very great. When the 
delirium persists, and the pulse at the same time becomes small 
and feeble, and the skin is covered with a cold, clammy sw^eat, 
death is imminent. In the algid variety, the prognosis varies wdth 
the intensity of the morbid phenomena. If the pulse entirely 
disappears, the danger is extreme. This suspension of the cir- 
culation, if it is continued for some time, is certainly followed by 
death. If the pulse can be still felt, although, only at considera- 
ble intervals, whatever may be the degree of coldness, we may 
indulge hope. When algid fever is accompanied by choleric 
vomiting and purging; when the face and extremities are blue, 
the breath cold, and the voice broken and sepulchral, death is 
almost inevitable. Vomiting without effort, as if by regurgitation, 
in the course of algid fever, with a moist, white, cold, and flat 
tongue, is always of fatal augury; it has appeared to me to be 
connected with extensive and chronic softening of the mucous 
membrane of the stomach."^ Maillot thinks that in most cases 
of fatal pernicious fever, there existed some chronic lesion, before 
the access of the disease. Dr. Charles Parry, in his paper on the 
congestive fever of central Indiana, says, — " Without treatment, 
or with the usual treatment of bilious fever, which is little better 
than none in this disease, probably three-fourths of the cases ter- 
minate fatally. But w'ith a special treatment, not more than one 
in eight. "^ 

"In the mean time," — says Clegho-a, — "it is to be remem- 

' Traite des Fievres Intermittentes. Par F. G, Maillot, p. 343. 
2 Am. Journ. Med, Sci., July, 1843. 



i 



MORTALITY AND PROGNOSIS. 373 

bered, that as in all acute diseases, so particularly in these fraudu- 
lent deceitful fevers, the presages either of death or recovery are 
not always certain and infallible ; it frequently happening that 
those who have laid in the paroxysm, for hours together, with few 
or no signs of life, have at length recovered, as it were, from the 
jaws of death, and asked for some uncommon sort of food, to the 
great surprise of everybody about them ; on the other hand, the 
fit anticipating sometimes brings on death before the time it was 
indicated."^ 

" Can we determine in advance," — says Maillot, — " whether a 
simple intermittent will or will not become pernicious in its cha- 
racter ? I think not. Frequently, we cannot do this, even at the 
commencement of a pernicious paroxysm. Without doubt we 
have reason to apprehend the approach of this perilous form of 
the disease, whenever any of the visceral irritations are intense, — 
whenever the symptoms of gastro-enteritis, or encephalitis, are 
strongly marked; but this rule has many exceptions, and I have 
often seen the most pernicious paroxysm succeed, without any 
premonition, to those of the simplest character."^ 

The prognosis is thus summed up by Cleghorn. ''If the pa- 
roxysms are not attended with acute pains in the viscera, and do 
not last above twelve hours; if they decline with plentiful warm 
sweats, and leave the intervals tolerably free; if the patient bears 
the distemper well, and begins to have an appetite for victuals ; if 
small pustules break out in the inside of the mouth, or scabs 
about the lips ; if the urine has recovered its natural complexion, 
or is cloudy and turbid, or lets fall a white or a pale red sediment ; 
— I say if all these signs concur about the third or fourth period, 
we may safely prognosticate a speedy recovery. On the other 
hand, it announces danger when, about this time of the disease, 
the paroxysms are long and protracted ; or are accompanied with 
an obstinate delirium, an intense coma, great anxiety, and pain 
in the loins, or about the upper orifice of the stomach ; when the 
patient has an utter aversion to food, and even in the intervals is 
so feeble, and attended with such a swimming in the head, that 
he can scarcely walk about; when the hypochondria and epigas- 
tric region are swelled, hard, and painful to the touch ; when 
numerous blotches, like the stinging of nettles, frequently break 

» Rush's Cleghorn, p. 103. 2 Traite des Fievres Intermittentes, p. 338. 



374 PERIODICAL FEVER. 

out on the skin; when the urine continues thin, clear, high 
colored, or covered with an ash-colored membrane, like a cob- 
web ; and lastly it announces danger, when larger evacuations 
come on than the strength can well bear, such as vomiting, purg- 
ing, bleeding of the nose, colliquative sweats, or the like. For 
fevers with these appearances sometimes are immediately changed 
into mortal dysenteries; sometimes they become continual ter- 
tians, and run out to a great length ; but, for the most part, they 
preserve the form of remitting or intermitting fevers, and daily 
growing stronger, prove very dangerous about the sixth or seventh 
period. 

" Those fevers are most to be dreaded, whose violence is greatest 
on the even days ; and if the paroxysm stops on the third, fifth, or 
seventh day, but continues on the fourth, sixth, or eighth day, 
we must be upon our guard, lest a sudden storm should succeed 
this treacherous intermission.^ * * Nor is there only a pos- 
sibility, in many cases, of foretelling the day, but likewise the 
hour, on which the patient will expire ; for that stage of the pa- 
roxysm, which he usually got over with the most difficulty, will 
most probably in the end prove fatal. I have seen some expire 
in what may be called the first stage of the paroxysm; the skin 
being chilled, and wet with cold sweats, their pulse small and 
irregular, and their senses entire to the very last. But the greatest 
numbers are hurried off in the height of the hot fit, stupefied, 
senseless, the breathing short and laborious, and the skin covered 
with a burning fiery sweat. "^ 

Maillot observes, that in the delirious variety of pernicious in- 
termittents, there is frequently a strong apprehension of approach- 
ing death, and that this feeling is always a fatal augury.^ 

Dr. Charles Parry observes, that the plethoric, young, and 
robust, are most apt to die ; and that the age, in a majority of 
fatal cases, is from twenty-five to thirty-five. 

The return of the paroxysm, in all the forms of periodical 
fever, at an earlier and earlier period of the day, is a favorable 
indication ; its appearance at a later and later period is unfavor- 
able. 

^ Rush's Cleghorn, p. 98. 2 Ibid., p. 103. 

s Traite des Fievres Litermittentes. p. 58. 



375 



CHAPTER VIII. 

DIAGNOSIS. 

The diagnosis of well-marked and uncomplicated cases of 
nearly all diseases is a matter, in the actual state of medical 
science, not often attended with any considerable difficulty. This 
is true of periodical fever. Under such circumstances, its several 
forms can be distinguished from each other, and from all other 
diseases, with great facility and certainty. The mark which is 
set upon these diseases by their family seal of periodicity separates 
them broadly and widely from nearly all other affections. It 
sometimes happens, however, that this seal becomes so blurred 
and indistinct, or is so nearly obliterated, as to lose much of its 
value, as a diagnostic and distinctive indication, and we are 
obliged to resort to other and collateral sources, for the true cha- 
racter of the disease. This happens most frequently under the 
following circumstances. In the w^armer malarious regions, and 
during the prevalence of the graver forms of periodical fever, the 
bilious remittent variety, especially, frequently loses, to a great 
extent, its periodical, or remittent character, and assumes more or 
less entirely a continued form. This modification usually takes 
place during the latter period of prolonged cases, and, under these 
circumstances, the resemblance between the disease and continued 
fever becomes very close; and this resemblance is frequently in- 
creased by the presence of typhoid phenomena, — great debility, 
feeble pulse, dry and brown tongue, tympanitic abdomen, diar- 
rhoea, and so on. It would be foolish to deny the difficulty, under 
such circumstances, of always distinguishing between this modi- 
fication of remittent fever, and continued fever of the typhoid cha- 
racter. The resemblance here is so striking, that the opinion has 
extensively prevailed, in this country, and still continues to pre- 
vail, that bilious remittent fever is not unfrequently changed in its 
progress into continued, typhoid, fever. The mistake here is that 
very common one of confounding the typhoid state^ or condition, 



376 PERIODICAL FEVER. 

present in many diseases, with specific, typlioid fever . But, not- 
withstanding this resemblance, and the difficulty which I have 
admitted, a careful study of the previous history of these cases, 
and of all the circumstances attending them, will generally enable 
us to come to a pretty positive conclusion, and to establish a 
pretty certain diagnosis. We shall almost always find, that during 
the first week or two of the disease, its remittent character was so 
decided as to remove all uncertainty as to its true nature. We 
shall find, further, in most cases, certain differences between the 
actual condition of the patient, and the phenomena of typhoid 
fever. The rose-colored eruption will be wanting; the low, mut- 
tering, and continuous delirium, w^th twitching of the tendons, 
and picking at imaginary objects, so common in grave cases of 
continued fever, will at least very rarely be as prominent and 
striking; and the periodical tendency, masked and crippled as it 
is, by the complication of local congestions and inflammations, 
will still, if closely watched for, frequently manifest its presence, 
by varioHS slight and irregular, but sudden, changes, such as are 
not often met with in continued fever. 

Dr. Stewardson says, that when the disease is prolonged, the 
remissions obscure, and the typhoid state present, the distinction 
between bilious remittent, and typhoid fever, may be rendered 
somewhat difficult; but that generally errors of diagnosis might 
be avoided by greater attention, and a more intimate acquaintance 
with the essential characters of the tvv'o diseases.^ 

During the paroxysm of the unmixed comatose, or delirious, 
form of congestive fever, the condition of the patient may be almost 
the same as in some local diseases of the brain. The history, and 
the collateral circumstances of the case, will generally be sufficient 
to remove all doubts as to its true nature. 

" If, as it frequently happens in the hospitals," — says Maillot, — 
" we had no previous knowledge of a patient, whom we find with 
coma or delirium, we might suppose the case to be one of acute 
meningitis, and resort at once to blood-letting, which, indeed, 
would be proper in either case. But the influence of the treat- 
ment upon the march of the symptoms would soon dissipate all 
doubt as to the nature of the affection. If it is a pernicious inter- 
mittent, and death does not take place during the paroxysm, the 

I Am. Jour. jMed. Sci., April, 1842. 



DIAGNOSIS. 377 

coma or the delirium will disappear in a few hours, the skin will 
cover itself with an abundant sweat, the pulse will become apy- 
rectic, and there will remain little or nothing of the condition, 
which, a few minutes before, so seriously endangered life. If, 
especially, all this happens in a malarious region, or during the 
prevalence of intermittent fevers, it is impossible to mistake a per- 
nicious paroxysm for any other disease. For it is not in this 
manner that acute, continued affections proceed. Look at a me- 
ningitis. As it is by degrees that it arrives at its highest point of 
intensity; as it is only after having continued for several days.that 
the headache gives place to delirium or coma, so, also, it is only 
by degrees that the symptoms subside. Never, as in a pernicious 
paroxysm, does the delirium of acute meningitis yield in the 
course of a few minutes; never is the coma dissipated with a 
rapidity that partakes of the marvellous. The abrupt cessation 
of very dangerous symptoms; — the calm w^hich succeeds to them; 
— their almost instantaneous reappearance : — such are the pheno- 
mena proper to periodical fever, and which we may in vain seek 
to find in continued affections."^ 

I have said nothing about the distinctions between the several 
forms or varieties of periodical fever itself. After the full descrip- 
tion that has been given of these varieties, it is hardly necessary 
to do this. I will merely observe, that all these forms and varie- 
ties may run into each other ; they are mutually convertible, and 
not fundamentally and specifically distinct, forms of disease. 

1 Traite des Fievres Intermittentes, p. 339. 



378 



CHAPTER IX. 

THEORY. 

An adequate and complete theory, even of the very simplest 
form of disease, is beyond the reach of our science ; and the dif- 
ficulties in the way of establishing such a theory increase with 
the increasing complexity and obscurity of the diseases, to which 
w^e wish to apply it. Still, as I have already intimated, I have 
no disposition to abjure entirely all attempts to explain and inter- 
pret the phenomena of disease ; I do not wish, because we can- 
not render our theories perfect, to reject them altogether. Science, 
here, as everywhere else, is in the appreciable phenomena, with 
which we deal, and in their ascertainable relations; but there is 
no objection to our endeavoring to interpret these phenomena, and 
these relations, provided, only, that we do so, with a clear com- 
prehension of the nature and scope of the task we have under- 
taken. Bearing in mind, that these interpretations are, in their 
very nature, more or less hypothetical and conjectural ; that they 
are entirely subordinate to the facts with which they are concerned ; 
that they may be false as well as true ; that they are never to be 
treated like the facts and their relations, which they attempt to ex- 
plain, as essential and constituent elements of science ; and that our 
absolute loyalty to the latter, is never to be impaired by any claims 
or pretensions of the former; — bearing these things always in 
mind, we may not only engage with safety in these explanations, 
— provided that we do so with becoming modesty and caution, — 
but they may even help us somewhat in systematizing and arrang- 
ing our knowledge. 

It can hardly be regarded as hypothetical to say, that there is a 
double element in the pathology of periodical fever. This double 
element consists of a perversion of the function of innervation, and 
of local congestions in certain organs and tissues. Maillot, and 
some others, refer the former of these elements to irritation of the 
cerebro-spinal axis. They think that this view is justified by the 



THEORY. 379 

phenomena during life, and by the alterations found in the brain 
and spinal marrow, and in their membranes, after death. Maillot 
looks upon this affection of the cerebro-spinal axis, not as a pure 
ordinary inflammation ., but as a nervous irritation^ — an active 
neurosis, — with a sudden raptus of blood to the organs. However 
this may be, it is quite certain, that one of the essential elements 
in the pathology of periodical fever, consists in some modification 
of the nervous system ; and it is nearer the truth, probably, in the 
present state of our knowledge, to say, that this modification is 
peculiar in its character, and obscure in its nature, instead of 
attempting to refer it to any of the ordinary and common morbid 
conditions of this system. 

It is possible that this lesion of innervation may constitute alone 
the pathology of periodical fever; the disease, in its purest and 
simplest form, may be without any other pathological condition; 
the local congestions in the liver, spleen, stomach, and so on, may 
be altogether wanting. This, however, it seems to me, is not the 
most probable and rational conclusion to be derived from the phe- 
nomena of the disease. There is no doubt of the general tend- 
ency to these local congestions ; there is no doubt of their existence 
in all grave and severe cases: they are always found on examina- 
tion after death. Under these circumstances, although in mild 
and simple cases of pure intermittent fever, there maybe no posi- 
tive evidence of the existence of these congestions, and although 
I admit the possibility that they may not be present, still, as I 
have already said, taking into consideration all the circumstances, 
it seems to me more philosophical and more rational, to conclude 
that they constitute an invariable and essential element in the 
pathology of this disease, than it is to regard them as accidental 
complications. 

The relations of the lesion of innervation, and of the local con- 
gestions to each other; and the relative and absolute importance of 
all these, — the parts which they respectively play in the integral 
disease which they constitute, — must be more or less matters of 
opinion merely. The nervous disturbance constitutes, probably, 
the first visible and tangible link in the chain of morbid action; 
it is, probably, the point of departure in the series of morbid pro- 
cesses making up the disease; it seems reasonable to suppose that 
it takes precedence of the local congestions, and that the latter 
are under the control of the former. All this, however, let it be 



380 PERIODICAL FEVER. 

admitted, may be otherwise; or, it may be that both elements, — 
the nervous lesion, and the local congestions, — instead of being 
dependent one upon the other, are alike occasioned by the action 
on the system, of the malarious poison, — their common and inde- 
pendent cause. 

In regard to the relative and absolute importance of the several 
morbid elements, I cannot say anything that is not altogether 
conjectural. The danger to life would seem to depend, generally, 
upon the intensity of the visceral congestions and irritations; but 
our knowledge of the nature of the nervous disturbance, and of 
the part which it plays, is so incomplete and so qualified, that it 
is neither very philosophical, nor very safe, to indulge to any 
great extent in these and similar speculations. It is safe, per- 
haps, to say that the element of penodicity is probably connected 
directly with the lesion of innervation, and not with the local con- 
gestions.^ 

Some of my readers, especially the younger ones, may be not 
a little disappointed that I do not engage in the attempt so often 
undertaken, to lift the veil which hides from us the efficient causes, 
the mechanism, and the essential nature of this mysterious and 
complex phenomenon o{ penodicity. For their gratification, and I 
trust for their benefit, I shall make tw^o or three remarks upon 
this subject, which, unlike the subject itself, will at least be suf- 
ficiently intelligible. First, then, all the interpretations and 
explanations \vhich have been given of this phenomenon, are 
entirely and absolutely hypothetical ; they are the coinage of the 
brain, — the fruits of the imagination and the fancy. Not only so, 
but in most cases, they are as obviously and glaringly absurd, 
preposterous, and false, as they are hypothetical. They have not 
even the merit of possibility, to say nothing of probability, plau- 
sibility, or ingenuity. Nowhere, perhaps, in the boundless region 
of medical speculation, has the rage for hypothesis been wilder 

• Hippocrates attributed tertians and quotidians to a superabundance of bile in 
the first passages, and quotidians to atrabile. Galen referred quotidians to an 
alteration of the pituita; tertians to that of the bile; and quartans to putrescence of 
the atrabile. The atomists said that quartans were the result of an obstruction 
occasioned by the minutest atoms; tertians by those a little larger; and quotidians 
by the largest. Rayer refers periodical fever to a cerebro-spinal neurosis; Gueriii 
de Mamers does the same. Brachet, of Lyons, says it consists in a modification of 
the ganglionic system. Bouillaud calls it an active neurosis. M. Roche refers it 
to a contamination of the blood by the malarious poison. — Maillol, p. 316, et seq. 



THEORY. 381 

and crazier than here. Secondly, the essential nature of this 
phenomenon is probably inscrutable. We may analyze it ; we 
may resolve it into its elements; we may ascertain the relations 
of these elements to each other, and to their modifiers, — we may 
do all this, and still be as far as ever from its ultimate cause, its 
essential condition, its intimate and absolute nature. Who under- 
stands, or can comprehend even, the nature of sleep^ And what 
reason is there to believe or to hope, that the thick darkness which 
has ever wrapped and which still wraps this intermittent physio- 
logical phenomenon, so full of mystery and wonder, will ever be 
dispelled'?^ 

* Darwin attributed the phenomenon of intermittence to the nutritive movement 
of composition and decomposition, and the periodical recurrence of waking and 
sleep. Reil taught that it was connected with the analogous phenomena of the 
physical universe. Willis referred it to the periodical development of a fermentible 
matter in the blood; De La Boe to the introduction into the blood of an acid, pan- 
creatic juice ; Borelli to an irritation of the nerves of the brain, and of the fibres of 
the heart, occasioned by an acidity or an acrimony developed in the nervous fluid. 
Werlhof referred it to the periodical movement of the earth, while Mead and others 
attributed it to lunar influence, to the alternate action of day and night, the direc- 
tion of the winds, &c. Giannini said intermittence was occasioned by the excessive 
diminution of sensibility during the sweating stage. Guerin de Mamers attributed 
it to an extraordinary development of nervous influence, its concentration upon a 
given point, its subsequent exhaustion, its renewal, and so on. M. Roche finds a 
sufficient explanation of this phenomenon in the intermittent character of its causes, 
and in certain other collateral influences. — Traite des Fievres Intermittentes, p. 270. 
Bailly, notwithstanding his general good sense, labors through many idle pages to 
show that morbid intermittence is occasioned by the diurnal change in the position 
of the human body, from the upright to the recumbent, and vice versa. Maillot con- 
cludes this enumeration with the following quotation from Monfalcon, — " To know 
that we know nothing is a great deal; ive are then much nearer the truth than when we 
mistake, for this latter, erroneous hypothesis^ 



382 



CHAPTER X. 

TREATltlENT. 

To combat the Tisoeial fcscass; to oppose the re ta rn of the paroxysms: to pre- 
Tent the occurrence of ireMpses: — sudh is tie triple base npon Trhich. rests the 
iTRa.tmp.Tit of periodical feTer.^ — ^Majxiot. 

ARTICLE I. 

BILIOtJS REMITTENT FETER. 

Sec. \.^—PreUmimwy. The treatment of the common fonn of 
bificiiis remitteiit feTer is pretty well settled ; and although the 
Taiieties in the character of the disease, in different seasons and 
localities, render nece^aiy certain modifications in the treatment. 
the essential principles of this remain the same. 

Sec. n. — Bhod-leUxng. General bleeding is not commonly 
resorted to in the treatment of this disease. There can be no 
doobty howCTer, that in robust and plethoric habits, and where 
there exists no contra-indication, either in the circumstances of 
the indiTidaal case, or in the preTailing character and constrhition 
of the disease, eariy and moderate general bleeding is of much 
ntflity- Eaily in the disease, under these circumstances, where 
the headache is Tiolent, the skin dry and hot, and the pnlse fuU 
and bonmding, the symptoms wiU be moderated by this remedy ; 
but in Ihe absence of these or analogous special indications, it 
would seem to be safer to abstain from general bleeding. Lind 
cautions against bleeding in hot climates. He says great harm 
has been done bjEn^ish practitioners, who followed the example 
(rf" Sydenham. Sir Gilbert Blane recommends bleeding, in athletic 
habits, with hi^ excitement, riolent pains, or delirium ; but he 
adds these words, — **Althoa^ l^e cases requiring blood-letting 
are more fireqnent in this sort of feTer than in typhus, yet great 
caution and nice discernment are necessary, with regard to it, in 



TREATMENT. 3S3 

all cases, in a hot climate. Blood-letting, unseasonably and in- 
judiciously employed, either endangers life, or has a very remark- 
able effect in protracting recovery, by the insurmountable weakness 
it induces."^ 

Topical bleeding, by cups or leeches, is of very great service, 
and of very general application. There are, probably, but few 
cases in which it may not be beneficially applied. This means 
is especially valuable for the removal, or diminution, of the epi- 
gastric pain, tenderness, and distress. In ordinary practice, cups 
will usually be made use of ; and they should be applied across 
the epigastrium, and the hypochondria, and repeated, according 
to the urgency of the symptoms, and the strength of the patient, 
until their object is accomplished. The best time for their appli- 
cation is during the febrile exacerbation, when the skin is warm 
and dry; and the earlier in the disease the better. "As regards 
the stage of the disorder," — Dr. Stewardson says, — "I should say 
that it was not worthy of much consideration in determining upon 
the propriety of local depletion in cases of an ordinary remittent, 
where considerable epigastric or hypochondriac tenderness coin- 
cided with more or less acceleration of pulse, and heat of skin. 
For although here, as in the more severe disease of hot climates, 
early depletion, i. e., from the first to the fourth day, is highly de- 
sirable, in order to shorten its course, and diminish the force of 
the local determinations, yet the same danger does not exist as in 
the latter, in reference to depletion at a much later period ; unless, 
of course, where the symptoms of prostration clearly forbid it. I 
would not hesitate, then, to abstract a few ounces of blood under 
the circumstances mentioned, even at a late period of the disorder, 
since it is certainly a point of paramount importance, in the treat- 
ment of remittent, to prevent, as far as practicable, the production 
of those chronic alterations of the spleen, and liver, which, when 
once firmly rooted, so generally prove fatal after lengthened suf- 
fering."^ 

Strong determination of blood to the head, indicated by head- 
ache, heat, throbbing, and in some instances delirium, requires 
the application of scarified cups to the temples, and back of the 
neck. 

' Diseases of Seamen, p. 389. 2 Am. Jom-. Med. Sci., April, 1S42. 



384 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

Sec. hi. — Purgatives. The use of purgatives in the treatment 
of bilious remittent fever is almost universal. In the United States, 
they are nearly always given at the commencement of the disease, 
and repeated, occasionally, during its subsequent course. Differ- 
ent combinations of cathartic substances are adopted by different 
practitioners ; but nearly all of them make use of some mercurial 
preparation, — either calomel, or blue pill. One of these substances 
is preferred on account of the peculiar action which they are be- 
lieved to exert upon the liver; and for their efficacy in restoring 
and correcting arrested or depraved secretions. "VMiatever may 
be the precise mode of action of the mercury, experience seems to 
have demonstrated its usefulness as a purgative in this form of 
disease. From five to ten grains of calomel may be combined 
with ten or fifteen grains of jalap, or with fifteen or twenty grains 
of rhubarb, to constitute a single purgative dose ; this may be re- 
peated, if necessary, or it may be followed by an ounce of castor 
oil. Instead of the calomel, ten or fifteen grains of blue pill may 
be made use of. 

Excessive purgation should be avoided. This evil, owing to 
the disastrous influences of a false and preposterous pathological 
theory, has been pretty extensively prevalent throughout many 
portions of our Southern and Western States. Happily for science 
and humanity, like the bastard philosophy whose legitimate off- 
spring it was, it has nearly run its race, and had its day, and is 
fast disappearing from the practice of our art. It is quite enough, 
as a general rule, that two or three consistent stools should be 
procured during each twenty-four hours, for the active period of 
the disease, and one or two, later. If there is intestinal irritation, 
still greater caution is necessary; and the milder laxatives should 
always be preferred. 

Sec. IV. — Cinchona, The periodical element in the pathology 
of this disease is to be met and neutralized by the great anti- 
periodic remedy, — cinchona and its preparations. There is no 
substitute for these. They are universally relied upon for this 
purpose. In all countries, and at all periods, since the discovery 
of the properties of this incomparable and invaluable substance: 
amidst all the conflicting dogmas of different medical doctrines, 
Peruvian bark has never failed to sustain its reputation, and to 
answer the expectations that have rested upon it. Amidst the 



TREATMENT. 385 

manifold uncertainties of medical science, and the perpetual 
contingencies of medical art ; amidst the disheartening scientific 
infidelity ^vhich has lately been taking possession of the medical 
mind, shaking to its deep foundations the firm old faith in the 
potency of drugs, and threatening to overturn and demolish it 
altogether, — it is gratifying and couvsolatory to feel and to know, 
that here at least we stand upon solid ground, that here we may 
hold, — that there is at leavSt one great and important therapeutical 
relationship definitively and positively ascertained and established, 
defying alike the open assaults of quackery from without, and the 
treacherous machinations of indolent skepticism from within. 

The sulphate of quinine is altogether the best of the prepara- 
tions of the bark, and it is now almost universally and exclusively 
used. There is a fjood deal of difference in the mode and cir- 
cumstances of its administration, by different practitioners, — a 
difference that is probably rendered necessary by modifications in 
the character of the disease itself. As a general rule, in the 
treatment of the common form of bilious remittent fever, practi- 
tioners desire to diminish the intensity of the local congestions 
and irritations, by depletion and purgatives; to lessen the general 
febrile excitement, and thus to develop the periodical element in 
the disease, by rendering the remissions more distinct, before re- 
sorting to the use of the quinine. Two or three grains an hour 
are then usually given during the period of remission. Some 
physicians prefer very much larger doses, — fifteen or twenty 
grains, for instance, — given at once, and repeated, if necessary. 
Other observers attach less importance to the preparation of the 
system, by blood-letting, cathartics, &c., for the quinine, and re- 
sort immediately, and without much regard to the stage of the 
disease, to its use. There seems to be good ground for believing, 
as I have just intimated, that these differences may have arisen 
from differences in the character of the disease. It appears pro- 
bable, for instance, that in the more northern and temperate lati- 
tudes, it is more necessary to prepare the way for the use of qui- 
nine, by the preliminary remedies before mentioned, than it is in 
the more southern and warmer latitudes. In these latitudes, the 
disease may sometimes assume a graver character than it wears 
in the former, verging towards its congestive co-gener, and re- 
quiring somewhat the same treatment that is necessary in the 
latter. 
25 



386 PERIODICAL FEVER.— CONGESTIVE FORM. 

Sec. v. — Diaphoretics; Refrigerants, ^c. Remedies of this 
class are generally made use of, especially during the height of 
the febrile paroxysm. Small doses of ipecac, nitrate of potash, 
and spirit of mindererus, are amongst the articles most frequently 
selected, — the choice depending upon the circumstances of the 
case, or the opinions of the practitioner. Cold drinks, acidulated 
or not, effervescing draughts, and so on, according to the taste of 
the patient, should be freely administered. 

ARTICLE II. 

CONGESTIVE FEVER. 

Although the general indications, in the management of the 
congestive variety of periodical fever, may be nearly the same as 
in that of the bilious remittent form, very important modifications 
are necessary, in the details of the treatment, and in the applica- 
tion of remedies. In no other disease, of so grave a character, 
does so much depend upon the prompt, efficient, and judicious 
interference of art; under no other circumstances, of ordinary 
acute disease, is the life of the patient placed so absolutely in the 
hands of his physician. A blow struck at the right time, in the 
right place, and in the right direction, will very often save the 
life that would otherwise have been lost. And the action of the 
physician in the treatment of this terrible form of disease is 
crowded into the briefest space of time ; the issues of life and 
death hang upon a single hour ; the morbid processes must be 
immediately arrested, or modified, or they will inflict irreparable 
and fatal injury upon the organs in which they are situated. 

In laying down rules for the treatment of congestive fever, I 
shall rely mostly upon the observation and experience of the phy- 
sicians of our southern and western states. They have long been 
extensively familiar with the disease, in all its phases, and in its 
gravest form ; they have studied carefully and attentively its the- 
rapeutical relationships; they have been, for the most part, suffi- 
ciently free from the influence of preconceived opinions, and 
doctrinal theories, to look steadily at nature and to follow its 
teachings; and I regard their authority upon this subject, as 
high at least as any in the world. There are, as might naturally 
enough be expected, some differences amongst them; but so far 



TREATMENT. 387 

as the most important and fundamental principles of treatment 
are concerned, they are very well agreed. 

I shall first speak of the means that are usually resorted to, 
during the cold fit, — a condition which appertains to all the va- 
rieties of the disease, — in what is commonly called the congestive 
chilly — in order to bring about reaction. External heat and stimu- 
lants, and internal stimuli, are generally relied upon for this pur- 
pose. Hot bricks, or bottles of hot water, are applied to the legs; 
and the surface of the body is extensively covered with sinapisms. 
Small quantities of brandy, or wine whey, porter, or some similar 
article, are frequently repeated internally. Jit the same time, the 
sheet anchor is to be at once thrown out, — the great remedy is to 
be immediately and boldly resorted to. The sulphate of quinine, 
usually in combination with some other articles, according to the 
circumstances and condition of the patient, is to be freely given. 
From ten to twenty grains of the sulphate should be administered, 
either alone or in combination with half a grain, or a grain, of 
one of the salts of morphia, with a few grains of calomel, or blue 
pill, according to the indications. 

Dr. Charles Parry, during the chill, applies hot bricks to the 
feet, and sinapisms over the belly and legs. Every half hour, he 
gives a pill composed of one-fifth of a grain of sulphate of mor- 
phia, one grain of camphor, two grains of blue pill, and some- 
times half a grain of capsicum. If there is much blood in the 
discharges from the bowels, and these are frequent, he gives 
every half hour one-fifth of a grain of sulphate of morphia^ three 
grains of sugar of lead, and two grains of calomel. He prefers 
ice, internally, to stimuli. If there is much purging, he makes 
use of opium; and to diminish the local congestions, he applies 
cups and ice. To prevent the return of the paroxysm, his great 
remedy is, of course, quinine. 

Dr. Wharton, of Grand Gulf, Mississippi, applies blisters to the 
thighs, and sinapisms over the belly. He administers at the same 
time, every hour or two, from four to seven grains of quinine, 
combined with capsicum and camphor. Brandy, he says, is 
often useful in promoting reaction. As soon as this is estab- 
lished, free doses of spirits of turpentine and castor oil are given, 
and repeated till they produce copious tarry discharges. 

Dr. Thomas Barbour, of Pulaski, Tennessee, has published in 
he American Journal of the Medical Sciences, an interesting 



388 PERIODICAL FEVER.— CONGESTIVE FORM. 

paper on the congestive fever of what is called the Tennessee 
valley, in North Alabama. His treatment of the disease dijBfers 
so much, in some respects, from that which is usually adopted, 
that I think it proper to give an outline of it. 

The principal peculiarities, in the method adopted by Dr. Bar- 
bour, consist of his means of procuring reaction, during the cold 
stage of the disease : — these means are bleeding, and the cold 
affusion. In ordinary cases, and where there is no contra-indica- 
tion, from age, intemperate habits, or feeble and broken-down 
constitutions, he bleeds cautiously, from the arm; keeping the 
finger on the pulse, and watching the effect. ^ If the pulse falters, 
the orifice is to be closed, and diffusible stimuli given ; but if it 
rises, and becomes fuller and more regular, as it often does, the 
operation is to be continued till the pulse is well developed. 
When general bleeding is not proper, free cupping is substituted. 
A sinapism is applied over the stomach, and small quantities of 
ice, or iced drink are given. If the bowels are torpid, he makes 
use of moderate doses of calomel, rhubarb and ipecac. ; if the 
discharges are thin, he suppresses them with moderate doses of 
calomel, camphor, and opium. He then resorts to the cold affu- 
sion, for the application of w^hich, he gives the following direc- 
tions. 

*' Have a broad plank placed upon two chairs, at a convenient 
distance apart, and place two vessels of hot water on each side, 
corresponding with the feet and hands ; then strip the patient and 
lay him on his back, on the plank, with his extremities in the hot 
water, — having at hand twenty or thirty gallons of spring w-ater, 
or what would be better, water made colder by ice or salt; pour 
the water from a pitcher, in a full and rapid stream, over the chest 
and abdomen. The second mode w^hich I adopt, particularly in 
cases where the brain and spinal marrow are the chief seats of 
congestion, is to place the patient upon a blanket on the floor, on 
his side, and then to dash the cold w^ater as forcibly as possible 
over the head, and along the spinal column. Having applied 
the w^ater, the patient should be quickly wiped and placed in bed, 
and covered with two or three blankets, and smartly rubbed, 
either with dry mustard flour, or salt, or with spirits of turpen- 
tine. 

"Under the combined influence of these agencies, reaction, if 
at all possible, soon ensues ; the surface rapidly recovers its na- 



TREATMENT. 389 

tural temperature ; the pulse, from being quick and thready, be- 
comes fuller, softer, and more regular; the countenance becomes 
fuller and more animated ; and from insatiable thirst, and uncon- 
trollable restlessness, the patient often experiences so much relief, 
that it is not uncommon for him to fall into a quiet and refreshing 
sleep, from which he awakes greatly improved. 

"The effects of the cold dash are, frequently, permanent; and 
complete reaction takes place, followed by rapid convalescence. 
In many instances, however, the effects of the first affusion sub- 
side, and the patient relapses into his former condition of coldness, 
restlessness and insensibility. In such cases, it is proper to repeat 
the affusion, until complete and permanent reaction takes place, 
which may be confidently anticipated in a large majority of even 
the worst cases, provided it is applied sufficiently early. "^ 

As auxiliaries to the cold affusion, Dr. Barbour generally ap- 
plies cups along the course of the spine, over the epigastrium, 
the right hypochondrium, or the bowels, according to the indica- 
tions; and stimulants to the skin. When there are strong marks 
of cerebral congestion, he applies a blister to the back of the head 
or the neck. He gives light diffusible stimuli, especially porter. 

When, by the above means, moderate reaction is procured, he 
gives from three to five grains of blue mass, five grains of rhu- 
barb, and from half a grain to one grain of opium, every six or 
eight hours, until the secretions become of natural color and con- 
sistence; and from ten to twenty grains of quinine, with from five 

> Relying upon what are commonly called rational indications, in the application 
of therapeutical means, nothing certainly can well be imagined, more absurd and 
irrational, more directly opposed to all a piiori considerations, than this use of gene- 
ral blood-letting, and the free affusion of iced water, to remove the collapse of a 
congestive chill. But these rational indications, as they are called, are very fre- 
quently, notwithstanding their high pretensions, most untrustworthy and treacherous 
guides ; they lead us astray as frequently as in the right path ; and whenever they 
oppose, as they so often do, the lessons of simple experience, they are to be utterly 
contemned and disregarded. It cannot be too often repeated, nor too emphatically 
proclaimed, that therapeutics rests on only one true and immovable basis, — that of 
pure observation; her steps can be guided aright by the light alone of experience. 
So here, as everywhere else, the utility and value of the new method are to be 
settled solely by its results. Its apparent unreasonableness or impropriety is not to 
stand in the M'ay of its adoption, if clinical observation establishes its utility. The 
practice is said to have originated with Dr. Thomas Fearn, of Huntsville, Alabama. 
Trial has been made of it by a considerable number of physicians; it deserves fur- 
ther and still more careful study; for its absolute value can hardly be regarded as 
definitely ascertained and determined. 



390 PERIODICAL FEVER.— CO>-GESTiyE FORM. 

to ten grains of Dover's powder, every three or four hours. He 
prefers the morniDg for the administration of the quinine, and the 
evening for that of the aperient. If reaction is violent, with signs 
of local cono-estion, he again applies cups, and administers calo- 
mel, followed by oil, or an infusion of senna with ginger, and 
repeats either the cold or the tepid affusion. It may sometimes 
be proper to bleed from the arm; but, under these circumstances, 
this should be done with extreme caution, as there is danger of 
excessive prostration. Where the cold stage is protracted for 
several days, with imperfect reaction, or none, Dr. Barbour thinks 
but little can be done; but he would rely, under such circum- 
stances, upon the occasional use of the cold bath ; large and nume- 
rous sinapisms, blisters, hot spirits of turpentine, calomel often 
repeated, large doses of quinine, and the free use of brandy or 
porter. Rice water, barley water, arrow-root gruel, or chicken 
water are the best articles of diet during the course of the disease, 
and also for several days ailer convalescence commences. After the 
strength of the digestive organs has somewhat improved, chicken 
broth, boiled milk, or milk and mush are appropriate for a few days, 
after which the patient can return to his usual diet. For drink 
during convalescence nothing is so good as old porter."^ 

^Maillot, an extensive and accurate observer, who saw much of 
periodical fever, in all its forms, in the French military hospitals 
in Africa, insists very strongly upon the necessity, in all the per- 
nicious or congestive varieties, of a prompt and bold use of the 
sulphate of quinine. He says, that his medical education and 
philosophy had impressed him with the common notion that qui- 
nine could not be safely given in these diseases, so long as there 
were signs of local irritation or inflammation present, and only 
during the apyrexy. His experience amongst the violent, con- 
gestive fevers of the hot malarious region of Algiers soon con- 
vinced him of his mistake ; and his use of the great remedy was 
as free and lavish, as that of any of our own practitioners in the 
southern and western states. During the paroxysm, in the comatose 
and delirious varieties, he recommends general and local blood- 
letting, and cold applications to the head. Cutaneous revulsives 
he also regards as important auxiliaries. In the algid variety, he 
endeavors to promote reaction by the free application of sinapisms, 

^ Amer. Journ. Med. Sci., Julv, 1S41. 



TREATMENT. 391 

and by large doses of ether, given both by the mouth and the rec- 
tum. He recommends that compresses, saturated with water and 
ammonia, be placed along the spine, over which is to be pressed 
a hot iron ; and that after their removal the parts shall be covered 
with sinapisms. He attaches but small value to cathartics. 

It will have been noticed, in the course of the foregoing details, 
that some of the most important rules of practice, followed by 
most of the older physicians, in the management of periodical 
fever, have been altogether disregarded. I allude particularly to 
the use of quinine, in very large doses, and at all periods of the 
disease, and without regard to those conditions of the system that 
have generally been supposed to contra-indicate its use. This 
mode of administering quinine is now almost universally adopted, 
in the grave forms of congestive fever, by the physicians of the 
South and West ; and both its necessity and its safety have been 
abundantly demonstrated. The paroxysms must he arrested, or 
the patient will die ; the only agent in our possession, by which this 
can be done, is the bark and its preparations ; and no time is to be 
lost in their use. There is no evidence, that in this form of fever, 
they have any tendency to increase the intensity of the local irri- 
tations. 

Dr. Thomas Fearn, of Huntsville, Alabama, more than fifteen 
years ago, gave the sulphate of quinine in doses of twenty grains, 
repeated three times, at intervals of one hour; and the credit of 
having originated this mode of practice has been given to him. 
The late Dr. Perrine, in a letter to Dr. Dewees, says that he used 
large doses of the bark, in the treatment of marsh fevers, given 
during the paroxysms, as early as 1819. As soon as quinine was 
introduced, he used that in average doses often grains, every two 
hours, at any period of the disease, without regard to the state of 
the pulse or skin. He did not find it to interfere with the simul- 
taneous use of antiphlogistics or stimulants.^ 

Maillot says, — " That treatment which in a malarious region 
attempts to remove local irritations before administering the sul- 
phate of quinine, which waits to convert a grave into a simple 
intermittent, before resorting to febrifuges, prepares for itself in- 
evitable reverses."^ 

Lind speaks of the Dutch in Batavia, as early as 1763, admin- 

' Transylvania Journal, vol, vi , p. 301. 2 Traite des Fievres, etc., p. 81. 



392 PERIODICAL FEVER.— INTERMITTENT FORM. 

istering bark, Avithout waiting for any remission ; and in grave 
cases, Cleghorn did the same in Minorca, a hundred years ago. 

About the modus operandi of the sulphate of quinine, I have but 
a single word to say. Certainly, there is no propriety in regard- 
ino- it as a simple tonic, or stimulant. In congestive fever, at 
least, it does not act as a tonic or stimulant ; and no known tonic 
or stimulant can be substituted for it, or supply its place. It is a 
specific anti-periodic. It is endowed with the peculiar property 
of arrestinof, or counteracting, this pathological process, charac- 
terized by periodicity ; it stands in a special relation to this par- 
ticular form of disease ; and this is the entire sum and substance 
of our knowledo^e of the matter, — -just as easily packed in a nut- 
shell as blown out into an empty balloon. 



ARTICLE III. 

INTERSnXTEXT FEAT:II. 

It is hardly necessary to enter, at any considerable length, into 
the details of the treatment appropriate to the simple, intermittent, 
form of periodical fever. The management of simple chills and 
fever has been, to a very great extent, taken out of the hands of 
medical men, and entrusted to those of the patients themselves 
and their friends. This management consists almost exclusively 
in the use of the sulphate of quinine ; with occasionally, perhaps, 
a simple or a mercurial purgative. The quinine is usually given 
during the intermission, and in various doses, — from one or two, 
to eight or ten grains. 

Amongst persons constantly residing in malarious localities, in- 
termittents frequently become obstinate, irregular, and protracted. 
In these cases, and in the simple forms, when the latter resist the 
influence of quinine, various substitutes for this substance have 
been made use of. Amongst these, the most important are arse- 
nic, and some of the bitter vegetables, — Cornus Florida, or dog- 
wood, chamomile, thoroughwort, and so on. There is no doubt 
at all of the anti-periodic property of arsenic ; and in those cases 
to which I have referred, it may sometimes be used with advan- 
tage. So, an infusion of one of the vegetables just mentioned will 
occasionally be found more efficacious in arresting the paroxysms 



TREATMENT. 393 

than even the bark itself; and Avhen the disease does not yield to 
its usual remedy, it is well to employ them. 

In regions where marsh fevers are extensively prevalent, there 
are many remedies, and modes of practice, besides those already 
mentioned, which acquire a popular celebrity. Most of them pro- 
duce a pretty sudden and powerful impression, either upon the 
mind or the body, and in this way they frequently break up the 
disease. I shall mention particularly only one other remedy, and 
that is opium. This substance has been a good deal used in the 
treatment of periodical fever, and there seems to be no doubt of 
its great value. The following interesting account of its action 
and etlects is by James Lind, who, for a long period during the 
last century, was a careful and extensive observer of periodical 
fever. His testimony in regard to its advantages is so emphatic 
and decided, that I feel bound to introduce it. The history of his 
experience is thus related. Having given a dose of opium in an 
obstinate case of ague, on account of some accidental symptom, 
to the great relief of the patient, he concluded to try the remedy 
more extensively. " Having, at that time," he says, ^'twenty-five 
patients laboring under intermitting fevers, I prescribed an opiate 
for each of them, to be taken immediately after the hot fit, provided 
the patient had any inquietude, headache, or similar symptom, 
subsequent to the fever. The consequence was, that nineteen in 
twenty-two received immediate relief; the other three had no oc- 
casion to take it. 

" Encouraged by this success, I next day ordered the opiate to 
be given during the hot fit. In eleven patients out of twelve, to 
whom it w^as thus. administered, it removed the headache, abated 
the fever, and produced a profuse sweat, which w^as soon followed 
by a perfect intermission. Since that time, I have prescribed an 
opiate to upwards of three hundred patients laboring under that 
disease. I observed, that when given during the intermission, it 
had not any effect, either in preventing or mitigating the succeed- 
ing fit ; when given in the cold fit, it once or twice seemed to re- 
move it; when given half an hour after the commencement of the 
hot fit, it generally gave immediate relief. 

" The effects of opium, given in the hot fit of an intermitting 
fever, are these: — First, it shortens and abates the fit; and this 
with more certainty than an ounce of bark is found to remove the 
disease. Second, — it generally gives a sensible relief to the head; 



394 PE1.ICBICAL FEVEP,— INTERMITTENT FORM. 

Tibf? :~ ^: z burning heat of tlie ferer, and occasions a profuse 
-r'-i' 7__.; s-weat is attended Tvith an agreeable softness of the 
skin, instead of the disagreeable burning sensation, 'which nsnally 
aiffects patients sweating in the hot fit, and is more copious than 
in tbose who are not nnder the influence of opium. Third, — ^it 
often produces a soft and refreshing sleep to patients before ha- 
rassed with ferer, from which they awake bathed in sweat, and 
in a great measure free from complaint. 

"I have always observed that the effects of opium are more 
imifcTm and constant in intermitting fevers than in most other 
di^^ases, and are then more quick and sensible than those of most 
other medicines. An opiate thus given, soon after the commenx^e- 
ment of the hot fit, by abating the violence, and lessening the du- 
Tsl^Ti isi the fever, preserves the constitution in a great measure 
lajHiBjored. Since I have used opium in agues, a dropsy or jaun- 
dice tas seldom attacked any of my patients in these diseases. 

^'In eases where opium did not immediately abate the symptoms 
of the fever, it never augmented their violence. On the contrary, 
most patients reaped some benefit from an opiate given in the hot 
fit; and many of them bore a larger dose of opium at that time 
than at any other. Even a delirium in the hot fit is not increased 
by opium : though opium will not remove it. K the patient be 
delirious in the fit, the administration of the opiate ougiit to be 
delayed till he recovers his senses ; an opiate will then be found 
to relieve the weakness and faintness which commonly succeed 
liie delirium.*'^ 

To prevent the occurrence of relapses I know of no means of 
any value, except an occasional use of the bark; a careful regu- 
lation of the diet and exercise, so as to keep the system in as 
■vigorous a tone as possible ; and an avoidance of the night air, 
and of all the ordinary exciting caases of disease. There is only 
one means certainly to be depended upon, and this consists in a 
removal beyond the influence of the malarious poison. 

For the remoral of the rarious remote consequences of the dis- 
ease, w^hich have already been enumerated, no very particular 
roles can be given. The local engorgements of the liver and 
^3een — especially of the latter — so long as they are simple en- 
gorgements, without any fixed change of structure, are to be met 

' Lind on Hot Cl im Rtes, Piiiia. ed., p. 236. 



TREATMENT. 395 

by the means already indicated, particularly by quinine, paying 
attention at the same time to the state of the bowels and secre- 
tions. When these engorgements have been so long continued 
and so often repeated, as to result in chronic structural alterations, 
only palliative effects can be looked for from remedies. The 
headache and other cerebral troubles, which sometimes follow the 
disease, and which seem to be connected with a kind of nervous 
erethism, may generally be removed by shaving the head and 
keeping it cool; by quiet and rest; and a careful regulation of all 
the organic and animal functions. Neuralgic affections are to be 
treated upon the same general principles. There can be but little 
doubt, that a free and persevering use of cold w^ater, externally 
and internally, with a plain but substantial diet, and active exer- 
cise in the open air, would constitute the best possible treatment 
in many of these cases. The best special remedy for the anemic 
condition which the disease frequently leaves behind it consists 
in the different preparations of iron. 



396 



CHAPTER XL 

DEFINITION. 

There is so wide and various a range in the forms of periodical 
fever, that it is very difficult to frame any definition of it, which 
shall possess the necessary brevity, and at the same time be suf- 
ficiently comprehensive to include all the essential features of the 
disease. I can come no nearer the fulfilment of these conditions 
than in the following endeavor. 

Periodical fever is an acute affection ; occurring at all periods 
of life ; much more common in the white than in the negro race ; 
confined to certain geographical localities, and prevailing most 
extensively, as an annual endemic, in marshy and uncultivated 
regions, and along low-lying and luxuriant alluvions ; mostly con- 
fined in temperate climates, to the latter part of the hot season of 
the year; immediately excited, in manyinstances, by the ordinary 
occasional causes of acute disease, such as exposure and excesses ; 
dependent for its essential cause, upon a poison called marsh 
miasm, or pialaria, the nature and composition of which are un- 
known; — generally, sudden in its access; commencing with a 
rigor, or chill, which is succeeded first by febrile excitement, and 
then by general perspiration, — these successive phenomena con- 
stituting the three stages of what is called the paroxysm of the 
disease ; this paroxysm having a tendency to recur, or to repeat 
itself, more or less regularly, at certain definite periods, and after 
certain intervals, — these intervals constituting the remissions or 
intermissions of the fever; the paroxysms and intervals being in 
an immense majority of instances, either diurnal or bi-diurnal in 
their recurrence; the symptomatic phenomena, constituting these 
periodical stages, varying very widely in their intensity and com- 
binations, thus giving rise to numerous, fluctuating, and diverse 
forms of disease; the simpler varieties attended with but little 
immediate danger, and continuing from a few days to an inde- 
finite period of time; the graver and pernicious forms dangerous 



DEFINITION. 397 

in their tendency, and speedily fatal in their results, unless 
promptly arrested by art ; all the varieties, if long continued, or 
often repeated, finally undermining the constitution, and occasion- 
ing various structural alterations, especially of the spleen, attended 
by dropsical effusions, anemia, general debility, and neuralgic 
pains: the bodies of patients exhibiting, on examination after 
death, in most cases, hypersemic irritation of the cerebro- spinal 
axis; in nearly all, redness, softening, thickening, thinning, and 
mamellonation — one or more — of the mucous membrane of the 
stomach; and in all cases, a bronze or olive color of the liver, 
enlargement and softening of the spleen, and a diminution in the 
normal quantity of the fibrine of the blood: — which disease, thus 
characterized and defined, sustains a special therapeutic relation 
to cinchona and its preparations, and is to a great extent modified 
and controlled by them. 



396 



CHAPTER XI. 

DEFINITION. 

There is so wide andTarious a range in the forms of periodical 
fever, that it is very difficult to frame any definition of it, which 
shall possess the necessary brevity, and at the same time be suf- 
ficiently comprehensive to include all the essential features of the 
disease. I can come no nearer the fulfilment of these conditions 
than in the following endeavor. 

Periodical fever is an acute affection; occurring at all periods 
of life; much more common in the white than in the negfro race: 
confined to certain geographical localities, and prevailing most 
extensively, as an annual endemic, in marshy and uncultivated 
regions, and along low-lying and luxuriant alluvions ; mostly con- 
fined in temperate climates, to the latter part of the hot season of 
the year; immediately excited, in many instances, by the ordinary 
occasional causes of acute disease, such as exposure and excesses : 
dependent for its essential cause, upon a poison called marsh 
miasm, or pialaria, the nature and composition of which are un- 
known; — generally, sudden in its access; commencing with a 
rigor, or chill, which is succeeded first by febrile excitement, and 
then by general perspiration, — these successive phenomena con- 
stituting the three stages of what is called the paroxysm of the 
disease; this paroxysm having a tendency to recur, or to repeat 
itself, more or less regularly, at certain definite periods, and after 
certain intervals, — these intervals constituting the remissions or 
intermissions of the fever; the paroxysms and intervals being in 
an immense majority of instances, either diurnal or bi-diurnal in 
their recurrence; the symptomatic phenomena, constituting these 
periodical stages, varying very widely in their intensity and com- 
binations, thus giving rise to numerous, fluctuating, and diverse 
forms of disease; the simpler varieties attended with but little 
immediate danger, and continuing from a few days to an inde- 
finite period of time; the graver and pernicious forms dangerous 



DEFINITION. 397 

in their tendency, and speedily fatal in their results, unless 
promptly arrested by art ; all the varieties, if long continued, or 
often repeated, finally undermining the constitution, and occasion- 
ing various structural alterations, especially of the spleen, attended 
by dropsical effusions, anemia, general debility, and neuralgic 
pains: the bodies of patients exhibiting, on examination after 
death, in most cases, hypersemic irritation of the cerebro- spinal 
axis; in nearly all, redness, softening, thickening, thinning, and 
mamellonation — one or more — of the mucous membrane of the 
stomach; and in all cases, a bronze or olive color of the liver, 
enlargement and softening of the spleen, and a diminution in the 
normal quantity of the fibrine of the blood: — which disease, thus 
characterized and defined, sustains a special therapeutic relation 
to cinchona and its preparations, and is to a great extent modified 
and controlled by them. 



400 



PERIOmCAI. FETER. 



plfltion; and I haTe been able to find but Terj litlle in if of anj 
Talne. 

pU €t Permdatses; dc. Par E. M, BmUy, de BIms. Paris, 
1825, iip. 535. 

This is a largs and isabstanlial treatise upon peiiodical feyer. 
Its antbor is a Frenchman, who sindied his sabject mo^j at 
Borne, in the jear IS,-. :ii::^-s: :^ir rrtients of Ihe great hos- 
pital of the Holy Spin: A. r - r: Ir ^ist Trainable portion of 



Ihe book is the first :::^ t 

pages. This is tdmL- :: 
statement and dcTel : : : i r 
mabire of peiiodical 
theories <rf waking £". s . r t : . : i 
merelj sajof it, fimt^-r:. . : l- 
intermittence to Ihe dinn^ - 
potation of Ihe human hoc 
tas^ to repeat the reasoniii _ 
It is a great pitj, that so sensible a 
importance to speculations so entii f 
great fault of the book consisis in 
constant effi>rts to explain and in: 
ease. There is nothing of anj sp 
peutics. The autihcn' inasts earc: : 
consttilating periodical r'eTfr, — ^ 
kical III 

fiHTlTT 

cal 7 . consist of b^ 

The _ t: r r^aids, not : 
Ear • riidic, and ne: 

lime 5 , ;_ T s : js, ^nA fiequei. 



iied and twenty^ 
' Teiy tedious 

:is about the 

7, &c., with 

: ^dll 



1 attach so much 

■-iimaiy. The 

: si^r, and its 

1 of di»- 

:. ;. : : 5-^fra- 



:e ol an ex- 



gaae - .J 7,:. -aigia. By Jokr. 

M. I .. ~. - > . I : :'!?ch Taults at : 

sadc-r :: 1:5 1: : . .:. _, :- the fiist sen" 

prei^i : :: :i ;: 1t l :_ :r " ::^ndence ; 

upoi. :i:r:_:::rL: I'T'^r:, T:_7 A:_!::.r :.'t: :^ "br ^: 
tobf :::ii :i :it i^l^is: ■::::i_:ri. rr:r_: i„i --:::, 
whi:.: ir 1:::; :75 :: „iLaria,inihe piodi: .ii :: 






BIBLIOGRAPHY. 401 

leading, philosophical error consists in this broad, loose, and 
sweeping generalization. Dr. Macculloch's style is involved and 
clumsy; but he writes from clear and strong conviction, and no 
one can wade through the episodical but racy prolixity of his 
heavy pages, without a strong feeling of his logical acuteness, his 
good sense, and his freedom from professional cant. His hardest 
and favorite hits, — well merited and w^ell put it, — are at Sangra- 
doism, asceticism, and the then fashionable practice of daily 
purging with "calomel and salts." There are other and more 
extensive localities than the British empire which might profit by 
his warnings. 

Sketches of the most prevalent Diseases of India. By James 
Annesley, Esquire; London, 1829. Mr. Annesley had ample 
opportunities for the study of periodical fever, in its several forms, 
during his residence in British East Indies ; but he has contributed 
A ery little in this work to our knowledge on this subject. There 
is no description of the fever, and the book is overloaded with gra- 
tuitous and hypothetical fancies, which the wTiter very sincerely 
and honestly mistakes for principles ! 

Traite des Ficvres, ou Irritations cerebro-spinales Intermittent es, 
d^ap?-es des observations recuielles en France, en Corse, et en Af- 
rique. Par F. C. Maillot. Paris, 1836, pp. 420. 

In an earnest and straight forward introduction of only five 
pages, M. Maillot awakens the interest and wins the confidence 
of his readers. He indicates the general character of his work, 
and makes amongst others these tw^o remarks. In the midst of the 
numerous works, he says, which have follow^ed each other upon 
this obscure subject of intermittent fever, there is one idea which 
is tending to become more and more predominant, namely, that 
which refers these fevers to a lesion of the nervous system. This, 
he adds, w^as the opinion of Boerhaave, of Cullen, of Borelli, of 
J. P. Frank, of Fodere, of Giannini, of Georget, etc. ; and in 
the present day of Alibert, Rayer, Bricheteau, Brachet, Nepple, 
and others. The cerebro-spinal axis he looks upon as the point 
of departure of the series of morbid actions constituting periodical 
fever ; but pathological anatomy has demonstrated, he says, that 
there is something superadded to the neurosis, and that this is an 
acute irritation or hypersemia of the great nervous centres. The 
treatment, he says, which consisted in removing or attempting to 
remove the local irritations and congestions, before the adminis- 
26 



402 PEBIODICAL F£¥£R. 

txation of cinchona was vJlowed, failed in hot climates and mala- 
rious regions; and it became necessary to fall hack itpon the 
method of Fore, that of gwmg large doses of this remedy dan i 
the paroxysm, and while the tongue indicated active gastric exciU- 
ment. I have made free use of Maillot's excellent and accnii r 
observations in Taiions parts of my book. He has contiibTi t 
laigely to our knowledge of periodical fcTer, especially as it shc"s 
itself in hot climates. Etcit part of his work abounds in positive 
and reliable information ; and it is generally pervaded by a Cc"- 
tious and sound philosophy. It is interesting to witness the ex?_ : ' 
coincidence between his convictions, — the result of extenave tz- 
perience, forced upon him in opposition to his previous opinio is. 
— and those of many observers in our own country, of the safr v 
and necessity of lar^e doses of qainine, in the graver ioims : 
periodical fever, regardless alike of any signs of local imta::::. 
or inflammation, and of the particular period of the disease. Ir- 
ene of his reported cases of comatose intermittent, occurring at 
Bona, in 1835, he gave, in the course of a few hours, eighty grains 
of sulphate of quinine, by the stomach, and sixty in an injection, 
all during the paroxysm. On the second day, the patient took 
forty grains, and twenty-four on the third; the following day, he 
was convalescent. 

Medical History of the Ejopedition to the J^^iga-y during the 
years 1841, and 1842, etc. By James Omdston M^WUUam, 
M.D. In the year 1841, an expedition was fitted out by the 
British government, to the river Mger in Africa, — ^the leading 
object of which was to promote the alxdition oS^ the slave trade. 
The expedition consisted of three iron steam vessels, the Albert, 
the Wilberforce, and the Soudan; and of one transport for stores. 
The expedition left England in May, 1841, and entered the Mger 
on the 13th of August. When the four vessels entered the new 
branch of the Niger, the following was their complement of officers 
and men, — many of the Kroomen and liberated African hojs 
having joined the vessels on the coast: — cheers, 53; — ^white 
seamen, 63; — marines and sappers, 29; — men of color entered 
in England, 25: — Kroomen and liberated Africans, 'entered on 
the coast, 110; — blacks for model farm, 23; — grand total, 303. 
The expedition went on very successfully, the <^cers and men 
all in good health and high spirits, until it had passed the delta 
of the river, and arrived at the town of Iddah, in the kingdom of 



BIBLIOGRAPHY. 403 

Eggana, nearly two hundred and fifty miles from the mouth. 
This was on the 2d of September, and on the 4th, fever of a most 
malignant character appeared in all the vessels. It spread with 
great rapidity ; and on the 9th, the first death took place, that of 
the captain's steward, of the Soudan. On the 11th, there were 
two deaths; on the 17th, there were sixty-nine sick, and there 
had been seven deaths. On the 19th, the Soudan, with forty 
cases of fever on board, started for the mouth of the river ; and 
on the 21st, the Wilberforce followed; leaving the Albert to go 
on her dreary way alone, — convoyed by tornados, tempests, 
savagery, pestilence, and death. By the 3d of October, the 
Albert having reached Egga, some three hundred and fifty miles 
from the sea, there were only seven persons on board well enough 
to do duty, and the Albert also abandoned the enterprize, and 
turned her prow towards the Atlantic. On the 8th, in the night, 
one of the patients, in delirium, jumped overboard, but was saved ; 
the next morning, the second engineer threw himself into the 
river, and was drowned. On the 17th, the three steamers arrived 
at the island of Fernando Po. ''On the 16th of December," — 
says Dr. M'William, — *'Dr. Vogel, the botanist of the expedition, 
died, and in the evening his body was deposited in the burial 
ground at Fernando Po by torch-light. It was pitch dark, and 
the stars, seen through the dense foliage, w^ere the only objects in 
nature that relieved the surrounding dismal gloom. At every 
step, we trod over our former messmates or fellow-laborers. As 
near as possible to the grave of Lander, lie thirteen of the Niger 
expedition, who, like himself, fell in the cause of Africa." The 
whole number of deaths from fever, during the expedition, was 
forty-two; all of which were amongst the whites. The whole 
number of whites, in the three steam-vessels, up and down the 
Niger, was one hundred and forty-five ; all these were attacked 
except fifteen. The whole number of blacks w^as one hundred 
and fifty-eight ; of whom only eleven had the fever, and these in 
a mild form. 

Dr. M'William's description of the disease is very incomplete 
and unsatisfactory. It was evidently remittent, many of the 
cases being congestive or malignant. There was no case of black 
vomit; and, indeed, there seems to have been little or no resem- 
blance between it and yellow fever; although Dr. M'William not 



404 PERIODICAL FEVER. 

only makes no distinction between the two diseases, but evidently 
Gonfounds them. 

Dr. M'William was sent in 1846, by the Admiralty Commis- 
sioners, to investigate the circumstances attending the prevalence 
of a malignant disease, at Boa Vista, one of the Cape de Verd 
Islands, in 1845. The disease, which was yellow fever, showed 
itself first on board the British ship Eclair, during the passage 
from the coast of Africa. It occurred at Boa Vista, for the first 
time, nearly a month aiter the departure of the Eclair. 

A Practical Medico-Historical Account of the Western Coast of 
Africa, etc. By James Boyle, London, 1831. Mr. Boyle occupied 
diiferent positions as a medical officer, in the British stations on 
the western coast of Africa, between the years 1822, and 1831. 
His volume, of more than four hundred pages, constitutes, he 
says, the first systematic treatise on the diseases of western Africa. 
It is very desultory and immethodical in its plan, and is written 
in an awkward and ungraceful manner. The first seventy pages 
are occupied with the medical topography of the western coast, 
from the river Gambia southward to Sierra Leone. Sluggish, 
muddy rivers, swarming with alligators, hippopotami, and mos- 
quitoes, their low banks covered with a rank growth of bush and 
mangrove ; deluging rains and devastating tornados, one-half the 
year, and the fiery and blinding harmatan the other; and an 
average temperature, during each of the twelve months, of at 
least 80° of Fahrenheit, make up the prominent features of the 
scene! Mr. Boyle describes two forms of endemic fever, — ^the 
climatorial bilious remittent, and the local endemic bilious remit- 
tent, as he calls them. There is no evidence that there is any 
essential difference between them. His descriptions of the African 
fever are very short, sketchy, and imperfect. The strongest im- 
pression left upon the mind by the reading of this book, is that of 
the terribly pestiferous and malignant character of this region, so 
far as the northern races are concerned. Surgeon Tedlie says, 
that although the Gold Coast has a moderate range of temperature, 
the mercury rarely rising higher than 85°, or falling lower than 
76°, it is more unfriendly to the European constitution than any 
other country on the face of the globe. No European, he says, 
ever escapes the fever. The first attack is the regular remittent, 
called the seasoning, after which the person is still subject to 
remittents and intermittents, more or less irregular in their cha- 



BIBLIOGRAPHY. 405 

racter. Yellow fever rarely occurs on the coast. It visited Sierra 
Leone in 1823, and 1829, attacking old residents as violently as 
more recent comers. 

The articles on intermittent and remittent fever, in the Library 
of Practical Medicine, are by Dr. Shapter. They are compila- 
tions, and so far from containing anything new, they are very far 
from embodying our actual knowledge upon the subjects of which 
they treat. 

The articles in the CyclopEedia of Practical Medicine are by 
Dr. Joseph Brown. The same remarks maybe made of them, as 
of the foreofoing:. 

The American Medical Journals contain many original articles 
upon the several forms of periodical fever of much value. 



PART FOUETH. 

THE 

HISTORY, DIAGNOSIS, AND TREATMENT 

OF 

YELLOW FEVER. 



PART IV. 
YELLOW FEVER. 

CHAPTER I. 

PRELIMINARY MATTERS. 

Sec. I. — Introductory. As I wish to be always on honest and 
fair terms with ray reader, I shall commence this fourth and last 
part of my book, by informing him that I am not personally fami- 
liar with the subject of which it treats. I have never met yellow 
fever at the bedside ; I have had no opportunities for direct and 
clinical study of the disease. 

Under these circumstances, there are many, probably, w^ho will 
think that it would %ave been more proper and becoming, on my 
part, not to have engaged in the task which I have undertaken. 
I wish to say a word or two, here, not exactly in apology for the 
course I have marked out for myself, but, in its justification. 
After the first edition of my book, consisting mostly of the history 
of typhoid and of typhus fever, with a short essay only on the 
diagnostic characters of periodical, and of yellow fever, was 
nearly exhausted, and I was making preparation for another, it 
was suggested to me by friends, on whose judgment I could 
rely, and whose advice I was disposed to follow, that the value 
and completeness of my work would be greatly increased by em- 
bracing within its scope a full history of all the fevers of the 
United States. This could not be done without including amongst 
them yellow fever. I succeeded, without any great difficulty, in 
persuading myself, that a person sufficiently familiar with the 
general forms and phenomena of disease, to enable him to distin- 
guish between the authentic and trustworthy experience of others, 
and that of a different character; between careful and careless 
observation, and competent and incompetent observers, — might, 
by a thorough and conscientious examination, analysis, and 



410 TWLUOfW FKVUIL 

azrafigement, of tiie msc^saaj materials, accomplish iradi aft Itir 
a leasonaUe de^ee «£ ^eoesB, a task like thsstiiefiiEe He. UnQer 
c|jt;aiB^ta&ce5, asd im 'flais ^irit. I have ^wtidced; asdicmce 
beg mj Mends to remember, and ^ : : t — y my profesmonal 
hirfiirefi cf liie SoHti^ aad Wer — ":^: r t i the nadks^ and 
BD^ ^exal pafioii£ of nj boc xi _^ . _ i ilaim 4e dfafno- 
lioB ci ad&g, except in the most inccmstderable de^se. Id cnrr 
absolote kaofwledge of the diseases of vhich I iiesi^ Imft i&att zi~ 
SBgle aim and purpose is the easier and hmribler hbe rf pns^i ■ 
ins: s clear and srstematic smnmaij of this tnowledgr " ; ii - 
readeis. 

Sec. n. — ^^ames of the Disease. Yellow fcrer has receire: i 
goodly number and Tariety of appeUatians; dis, r- ~'-~ "~ - 
name -with Knglish, French, and AmfaiBt %r 

its na^tnral histoiy, die j^aw dEboaloEation of the ^da. 0bc of 
its eaiiiest; ^ames was Aat <af amI ^ Stom, — disease'cf Sbm^ — 
£TSt giren to it by 6ie DdnisicaB, hAer Lsiba^ near the dne of 
the sei^^dees^ eexiny, firaM Hk bcfief dbat k was dim««d S^om 
tltat fsranlxy. Oo^oIm edk k a i Jilig^JMai P wli i frfi a l Ferer ; 
Lempdere calls it Tropical GoadiiiiLed FeTer; ffiiiiil calk k 
Me^^esiamtaM. Fer^; maaj caM k the Bulam or Bd^sb Fetcr; 
and ¥aiims o&er names kave Iwea applied to it Kmnrngnt. Ike 
masj Bases ^hich systemadc wzkos iraie applied to k ase l&e 
ftfioidbi^ — to wit, — ^TypkiK ktendes; Ekdes icteitadeB; FcMb 



411 



CHAPTER II. 

SYMPTOMS. 
ARTICLE I. 

MODE AND PERIOD OF ACCESS. 

Yellow fever is almost always marked by a distinct and formal 
access, so that the precise period of its commencement can be 
generally fixed with great precision and certainty. The most 
constant initiatory symptoms are chills ; and pains, often violent, 
in the head, back, and limbs, — the latter not unfrequently being 
very severely felt in the calves of the legs. Dr. Barrington, in 
his account of the disease, as it prevailed on board the vessels of 
the United States Navy, and at Pensacola, in 1828, 1829, and 
1830, says, that in a few cases, the fever was ushered in by an 
acute pain felt in some spot, and afterwards becoming general. 
"In one patient, on board the Grampus, the penis was the seat of 
this suffering; in another, the attack was announced by a neu- 
ralgic affection of the right temple. In several, the knees were 
alone complained of at first ; and in four patients, in the Hornet, 
a spasmodic affection of the muscles of the leg was the prelude."^ 
In what proportion of cases, this well-marked commencement of 
the disease is preceded by premonitory symptoms, I am unable to 
say, with any degree of accuracy; the statements of most ob- 
servers, upon this point, being made only in general terms. It 
is quite certain, however, that in many instances, the person re- 
ceives no warning of the approach of the disease ; he is stricken 
down in an instant, no shadow of the coming blow having fallen 
upon him. Dr. Rush, in his description of the yellow fever of 
1793, in Philadelphia, says, — " many went to bed in good health, 
and awoke in the night, with a chilly fit. Many rose in the morn- 
ing after regular and natural sleep, and were seized at their work, 

* Amer. Journ. Med. ScL, Aug., 1833. 



412 Till Jz zj 

or after a walk, with a siilirn and unexpected attack of the 
feTcr."^ Dr. Bairington says, that in a majoiitj of instances, the 
fflise' ~'c-s -^r\-.iit any preTions indisposition. 

Il :it: jLSrs, this distinct commencement of the disease is 
pre : r : : r some hours, or for some days, by certain premoni- 
tor^. ._ :zis. There is nothing constant or inraiiable in the 
ch^: : r ; ihese ; sometimes they consist of moderate febiile ex- 
citement, and at others of Tarious distorbances of the nervous and 
dige^Tc fbnctions. Dr. Rash enumerates nearly twenty of these 
precursory ^gns; but they are, none of them, sufficiently uniform 
in their occurrence, or sufficiently characteristic of the disease, to 
render it worth while to repeat them. 

It is alleged by many observers, that the attack of yellow fever 
occurs much more frequently during the night than during the 
day. Dr. Rush says, — " A great proportion .of all who were 
afieeted by this fever were attacked in the night.'" Dr. Barring- 
ton says, that the time of the or. 5 e : "as 1 - :. \ y between sunset 
and sunrise.' Dr. T. A. Cooke, iz. - 7 : . 'he New Orleans 

Medical and Surgical Journal, ol t E 1 Yellow Fever 
which prevailed at Opdousas, in th e y r v 1 ^ : * . 1 : : / . ? id 1842. 
says, that in the two former years, .. r ? n r 

rarely with premonitory symptoms, iii. :. i .i:^ 
cases, between the hours of midnight and daybreak. I 
know that this great liability to an attack of the disease c : 
nig^t is formally contradicted by any writers; but there a 
who say nothing about it; and it can hardly be regarde : 
unreasonable skepticism to say, that the question must b( 
mined by further, more extensive, and more accurate observation. 
In his description of the epidemic of 1828, at Gibraltar, Louis 
merely remarks, that the disease commenced at different hours ol 
the day, sometimes in the night ; and I find, on looking over the 
only cases, seven in number, reported by him, in which the time 
of attack is particularly mentioned, that this was during the day 
in two; at five, P.M., seven, P. M., and eig^t, P.M., in one each; 
in the morning, in one ; and in the night, in one. Of five cases, 
occurring in tbe Ch?Ti^v Hospital, at New Orleans, in 1843, and 
reported :.y L:. St. t: attack took place during the day in 
one; and at five. A. M.. e:--.i:. A. M., and eleven, A.M., in one 

» fine's Med I iai. p. 5(2. 

* Bi^3 Med. : -_ . :ip.5l. » Amer. Joar. MedL Sci, Ang., 1833. 



_ 1, 



>C UC.Ci- 



SYMPTOMS.— CHILLS.— SKIN. 413 

each.^ Dr. E. B. Harris has reported twenty cases, which oc- 
curred at New Orleans, in 1833. The time of attack is particu- 
larly stated in sixteen, and in only two of these was the attack in 
the night. ^ 

ARTICLE II. 

FEBRILE SYMPTOMS. 

Sec. I. — Chills. There is probably no disease, unless it is 
puerperal peritonitis, the access of which is more invariably at- 
tended by a chill, or rigor, than this. The testimony of observers 
is so uniform upon this point, that it is quite needless to accumu- 
late authorities. It is present alike in mild, grave, and fatal cases, 
with one exception, perhaps, which will be mentioned hereafter, 
in speaking of a very singular and striking form or variety of the 
disease. The chill is almost ahvays one of the first symptoms ; 
although, in a very few cases, it takes place some hours, or even 
a day or two, after the formal commencement of the fever. The 
chill is sometimes severe, but generally moderate, of short dura- 
tion, and is rarely, though it is occasionally, repeated. 

Sec. II. — Temperature of the Surf ace ; — Sweats. Following the 
initial chill, there is frequently increased heat of the surface; hut 
this heat is only moderate. The high and burning heat of con- 
tinued fever, and of some of the eruptive fevers, is never present; 
and in very many cases, the skin never rises above its natural 
temperature. The increased heat, in those cases where it is pre- 
sent, rarely continues beyond the second or third day; rapidly 
giving place, in cases that are running on tow^ards a fatal termi- 
nation, to coldness of the surface, beginning usually in the extre- 
mities, and more striking here than in other parts of the body. 
According to Louis and Trousseau, coldness of the lower extremi- 
ties is a very constant attendant upon the hlack vomit, a symptom 
that w^ill be particularly described hereafter. 

In a certain number of cases, there is more or less perspiration; 
I a others, the skin preserves its natural softness and moisture; it 
is not often morbidly dry. Dr. Lewis, of Mobile, says, there is a 
natural tendency to perspiration. Dr. John Wilson says the state 

' N. 0. Med. and Surg. Jour., vol. i. p. 86. 2 Amer. Jour. Med. Sci., May, 1834. 



414 YELLOW FEVER. 

of the surface differs in the two forms of the disease, — the inflam- 
matory, and the congestive. "In the former, the heat of the skin 
is high, free, and diffused ; it impresses the hand instantly and 
powerfully, being nearly as intense at the extremities as at the 
centre, sometimes even more so. In the latter, the heat of the 
surface is frequently less than in health, particularly on the extre- 
mities. When it equals or surpasses the healthy standard, as it 
sometimes does, being highest about the epigastrium, it is of a 
peculiar kind. The hand is scarcely impressed by it, when 
applied lightly and hastily to the pit of the stomach, but when 
kept there with steady pressure, a sensation of deep-seated and 
accumulated heat is communicated. * * * With this peculiar con- 
dition of the surface as to temperature, there is connected a pecu- 
liar want of tone in the skin, which it is difficult to render intelli- 
gible by description. It is sometimes dry, harsh, and dense; 
sometimes moist, with a thin, serum-like fluid, or a greasy exuda- 
tion; sometimes it is smooth, slippery, inelastic, and doughy, 
without moisture ; but in whatever manner its functions may be 
perverted or abolished, its characteristic condition is w^ant of 
vitality: when grasped in the hand, and raised from the parts 
beneath, it feels like the skin of one w^ho had ceased to breathe."^ 
The color of the skin will be more appropriately noticed in ano- 
ther place. 

Sec. III. — Pulse. It is not an easy matter, for one w^ho has 
never felt the pulse of a yellow fever patient, to form any very 
distinct and clear idea of its character and peculiarities ; so con- 
tradictory, and sometimes so apparently fanciful, are the descrip- 
tions of it by different observers. On one point, however, and 
that is, its frequency, there is great uniformity in the statements 
of writers. The pulse never reaches the frequency that is so 
common in nearly all other febrile and inflammatory affections. 
Louis and Trousseau, at Gibraltar, even in cases that terminated 
fatally, never found it higher than a hundred in a minute, and 
this in only five instances, and for a single day. In cases that 
recovered, they generally found it only slightly accelerated, and 
this for a day or two only, at the beginning of the disease, after 
which it rapidly fell to its natural standard.^ 

* Memoirs of West Indian Fever, p. 20. ' Louis on Yellow Fever, p. 208. 



SYMPTOMS.— PULSE. 415 

As to its other characters, it is commonly described as natural, 
or more or less full, tense, and bounding. In eight fatal cases, 
Louis and Trousseau found it large and vibrating in one ; a little 
stronger than natural in two ; almost natural in two, and small 
and serrated in three. Amongst the patients who recovered, they 
found the pulse large and rather full on the second or third day 
of the disease, in half the cases; small and feeble during the first 
days, in only two cases ; and natural in the rest.^ It is generally 
regular, but sometimes unequal and intermittent towards the close 
of the disease. Dr. Rush devotes more than three full pages to a 
description of the pulse, a considerable portion of which descrip- 
tion is not particularly clear or intelligible. He mentions several 
occasional peculiarities of the pulse, such as irregularity, inter- 
mission, preternatural slowness, and so on. He has a great deal 
to say about a small, intermitting, tense, corded and slow pulse, 
which he thought was peculiar to certain forms of yellow fever ; 
which one of his pupils characterized as an undescnbable pulse, 
and which he called a hobbling, or a sulky pulse. ^ My personal 
friend and former pupil. Dr. P. H. Lewis, of Mobile, has pub- 
lished in the first volume of the New Orleans Medical and Sur- 
gical Journal, a valuable and interesting paper on the yellow fever 
of that city, to which I shall have occasion frequently to refer. 
His observations were mostly made amidst the hurry and confu- 
sion inseparably attendant upon epidemic visitations of disease, 
and they necessarily partake somewhat of the imperfections, un- 
avoidable under such circumstances; but they are marked by 
carefulness, acuteness, and conscientiousness, and they constitute 
a valuable addition to our knowledge of yellow fever. Dr. Lewis 
says, that during the sort of remissio7i, which follows the first 
fobrile reaction, and which he calls, after a medical friend,, the stage 

' Loixis on Yellow Fever, p. 209. 

2 Dr. Rush, enlightened by the blaze of that luminous philosophy which sur- 
rounds all his medical writings, met with no difficulty in understanding and account- 
ing for this perverse and unreasonable pulse; he said it was occasioned by a spas- 
modic affection, accompanied with preternatural dilatation or contraction of the 
heart ! The slow, feeble, and intermittent pulse have been improperly ascribed, 
says Dr. Rush, to the absence of fever. They are occasioned, he adds, "by the 
stimulus of the remote cause acting upon the arteries with too much force to admit 
of their being excited into quick and convulsive motions;" there being a deficiency 
of strength in the artery from an excess of force apphed to it, as Milton describes 
a darkness from an excess of light! The illustration from Milton is Dr. Rush's, — 
not mine. 



416 YELLOW FEVER. 

of calm^ the pulse is usually about or below par, and to many 
would appear natural. " But, so far from being normal," — he 
adds, — "there are gentlemen in Mobile, who, blind-folded, can 
separate it from all others. It comes up to the finger like an air 
bubble, and rebounds under the least pressure ; again, there is 
not that strength and lengthened vibrating feeling, which belong 
to the healthy pulse. Dr. Childress, who has been practicing in 
the south thirty-five years, remarked to me, that it was the most 
deceptive pulse he had ever felt ; at first appearing natural, but, 
upon examination, there was none of it^ This pulse is spoken 
of by Dr. Lewis, in another place, as full and bubblingy compres- 
sible and gaseous, rebounding under the least pressure of the 
finger. He says, also, that in twenty cases, in which the three 
stages, — the febrile, the stage of calm, and that of collapse, — 
were well defined, he found the mean range of the pulse, for two 
days, between 90 and 115, for one day about par, and for three 
and a half days below par ; the average range of the pulse during 
the whole course of the disease being rather below the natural 
and healthy standard. This compressible character of the pulse 
is particularly noticed by some of the older writers. Chisholm 
says, — "It is observable, that in several cases, the slightest pres- 
sure could produce a cessation of pulse. "^ A sufficiently obvious 
reason for the contradictory descriptions which are to be met w^ith, 
of the pulse in yellow fever, may be found in its different charac- 
ters in the different forms and stages of the disease. Dr. John Wil- 
son says, that in the inflammatory variety, the pulse is remarka- 
ble for its strength, forcibly repelling the finger, and not yielding 
to ordinary pressure. In the congestive form, he says, it is 
always w^eak. "It offers no resistance to the touch: when the 
finger is applied to an artery, it acts as it would on an inanimate 
elastic tube half full of fluid; it depresses easily the point on 
which it bears into contact with the opposite point, the contents 
receding in either direction. This state of the pulse is so striking 
and characteristic, that I think it can scarcely be overlooked or 
misapprehended."^ 

1 Chisholrn's Essay, vol. i. p. 162. 

2 Memoirs of the West Indian Fever, p. 19. 



SYMPTOMS.— TONGUE.— APPETITE AND THIRST. 417 

ARTICLE II. 

DIGESTIVE AND ABDOMINAL SYMPTOMS. 

Sec. I. — Tongue and Mouth. The tongue is generally moist, 
and more or less coated with a light-colored, whitish, or yellowish- 
white, villous fur. It is sometimes red, and towards the close of 
life in fatal cases sometimes dry, red, and cracked, like the tongue 
of continued fever. In many instances, it remains nearly natural, 
through the entire course of the disease. Dr. Rush says, — "the 
tongue was in every case moist, and of a w^hite color, in the first 
and second days of the fever. As the disease advanced, it assumed 
a red color, and a smooth, shining, appearance. It was not quite 
dry in this state. Towards the close of the fever, a dry black 
streak appeared in its middle, which gradually extended to every 
part of it.^ Dr. Gillkrest says, the most characteristic appearance 
of the tongue is that of the pasty surface, with red edges and 
apex; and, further, that the red, or, as it has been called by 
some, crimson, border of the tongue ranks among the most cha- 
racteristic signs in the first stage of the malady.^ Bally and 
some others, especially amongst Spanish observers, speak of an 
abundant spontaneous salivation as a common occurrence. It is 
rare to find sordes on the teeth. 

Sec. II. — Jippetite and Thirst. It is a little singular how gene- 
rally writers upon yellow fever neglect to give any particular 
account of the state of the appetite; many of them indeed make 
no mention of it whatever. Even Louis and Trousseau say nothing 
special about it. Dr. Rush says, — " The appetite for food was 
impaired in this, as in all other fevers, but it returned much 
sooner than is common, after the patient began to recover. Coffee 
was relished in the remissions of the fever, in every stage of the 
disease. So keen was the appetite for solid, and more especially 
for animal food, after the solution of the fever, that many suffered 
from eating aliment that was improper from its quality or quantity. 
There was a general disrelish for w^ine, but malt liquors were 
frequently grateful to the taste. Many people retained a relish 
for tobacco much longer after they were attacked by this fever, 

' Rush's Med. Inq., vol. iii. p. 63. 2 Cyc. Prac. Med., vol. ii. pp. 270, 273. 

27 



418 YELLOW FEVEE. 

and acquired a relish for it mucK sooner after they began to 
recover, than is common in any other febrile disease. I met 
■with one case, in which a man, who was so ill as to require 
two bleedings, continued to chew tobacco throuorh every stage of 
his fever."' 

The remark that has jnst been made in regard to the general 
omission by writers on yeEow fever of any particular description 
of the state of the appetite is also applicable to the thirst: by 
many, this symptom is not mentioned at all, and by most others, 
it is spoken of only incidentally. It would seem as a general 
rale, to be only moderate. Dr. Rush says, — "The thirst was 
moderate or absent in some cases, but it occurred in the greatest 
number of persons whom I saw in this fever. Sometimes it was 
Tery intense. One of my patients, who suffered by an excessire 
draught of cold water, declared, just before he died, that he could 
drink up the Delaware. It was always an alarming symptom, 
when this thirst came on in this extravagant degree in the last 
stage of the disease. In the beginning of the fever it generally 
abated, upon the appearance of a moist skin. Water was pre- 
ferred to all other drinks."^ Sir Gilbert Blane says there is no 
excessive thirst.^ Dr. Deveze, in his description of the Philadel- 
phia epidemic of 1793, says, that during the first stage, the degree 
of thirst corresponds to the febrile heat ; and that in the second 
stage it is unappeasable."* Bally says there is rarely any con- 
siderable thirst; and he quotes Jackson, Chisholm, and Clark, to 
the same effect.^ Dr. Lewis of Mobile, in a letter to me, dated 
September 26th, 1S47, says, — "In genuine yellow fever, the 
thirst is not urgent. It is true the patient often says he is thirsty; 
that he wishes he had a cold stream running throu^ him ; but 
when water is handed to him, he drinks very sparingly, sayins: 
that it lays on his stomach, or produces pain at the epigastrium. 
Others have no desire for cold drinks, but take warm tea without 
objecting." 

Sec. m. — JVdusea and Vomiting. Amongst the most constant, 
and, in certain circumstances, the most strikino: and characteris- 
tic, phenomena of yellow fever, are nausea and vomiting, espe- 



.^s Me<L Inq., toL iii p. 67. 2 IbicL, p. 66. 

3 Observations, &c_ p. 404. ^ Traite de la Fieyre Jaane, p. 22. 

3 Da Typhus d'Amerique. Par Yr. Ballyj p. 216. 



SYMPTOMS.— NAUSEA AND VOMITING. 419 

cially the latter. In a certain proportion of cases, the vomiting 
occurs in the course of the first day of the disease; in the others, 
on the subsequent days, from the first to the fifth. In cases, 
which terminate fatally, the vomiting almost always, after it has 
commenced, continues to be repeated, at longer or shorter inter- 
vals, till the death of the patient; sometimes however the vomit- 
ing ceases a day or two before death. In cases which terminate 
in recovery, the vomiting usually ceases after having been present 
a few hours only, or from twenty-four to forty-eight hours. The 
matters vomited consist, at first, usually, of the fluids that have 
been taken into the stomach; they then become yellowish or 
greenish, and in patients who recover, they do not generally pre- 
sent any other appearances. In cases, how^ever, which are to 
terminate in death, these vomitings soon give way to the well 
known and fatal hlack vomit. This peculiar and striking symp- 
tom sometimes commences thirty-six or forty-eight hours before 
death ; but more commonly not till the last day of life.^ Louis 
and Trousseau's particular description of the appearances of the 
matter of black vomit, as found in the stomach and intestines, 
will be given in the chapter on the post-mortem phenomena of 
the disease. It is generally described as resembling coffee 
grounds. Dr. Rush made a distinction, however, betw^een this 
kind of fluid, and the true black vomit ; I suppose that the former 
was only the early stage of the latter. Dr. Lewis, of Mobile, 
gives the following account of the gastric symptoms. "As a 
general rule, there are far less vomiting and irritability of stomach 
during the first stage of yellow, than that of bilious, fever. During 
the stage of calm, a mucus, containing little flocculent masses, 
resembling hees'' wings, is sometimes vomited. If bile is ejected, 
it may be set down, not only as an exception, but a favorable in- 
dication. The black vomit, which takes place in the collapse 
stage, is of various consistence and appearance. The little 
masses which have been likened to hees"^ wings occasionally 
deepen, so that by the time the disease arrives at the collapse 
stage, it assumes the appearance of a thick black mass. The 
vomit is more generally thin and black, w-ith a coffee-ground 
sediment; this is \is>\i?i\\j pumped up, suddenly, and without pre- 
vious warning. The patient complains of its being sour, and 

• Louis on Yellow Fever, p, 217. 



420 YELLOW FE^ER. 

SO Yery acrid as to scald tke throat. Black Tomit, in a few in- 
stances, made its appearance on the night of the second day after 
the attack. These were exceptioiis, the fourtii stnd fiffli day 
being the most nsnal. Many cases terminated fatally in which 
this symptom was wanting.''^ Blood but slightly changed is 
sometimes vomited. The easy, sudden, pumping character of the 
act of Tomitins:. in these cases, mentioned by Dr. Lewis, is spoken 
of by other observers. Several patients, says Louis, appeared to 
Tomit without efibrt, the basin being placed on the edge of the 
bed, and their heads supported on their hands. Dr. Lewis, asrain, 
in his account of the treatment of yellow fever, remarks, incident- 
ally, that there are less nausea and retching, than in bilioiis fever; 
and that, "the stomach is frequently disgorged without any other 
symptom than a slight tremulous curl of the upper lip, and a con- 
sciousness, on the part of the patient, that his stomach is in a 
rebellious mood."^ Dr. Rush says, — "The contents of the sto- 
mach were sometimes thrown up with a convulsive motion that 
propelled them in a stream to a great distance, and in some in- 
stances all over the clothes of the by-standers." 

Sec. Pv". — Bowels; Abdomen; Epigastrium. The bowels are 

generally costive ; at least there is rarely any tendency to diar- 
rhoea. The only striking peculiarity in the character of the dis- 
charges consists in their brownish, or black color. This symp- 
tom, like the black vomit, is found in a large proportion of the 
fatal cases ; it occurs towards the close of the disease, but on an 
average, a little earlier than the black vomit. It depends upon 
the same cause. It occurs also in cases which terminate in reco- 
very, but in a much smaller proportion.^ 

Colicky pains occur in different parts of the abdomen, in a cer- 
tain proportion of cases, and durins: a limited period of time. 
They are sometimes occasioned by cathartic medicines; and, ac- 
cording to Louis, their commencement often coincides with the 
appearance of the brown and black stools. The shape and feel 
of the abdomen are nearly always natural, through the entire 
course of the disease. 

Epigastric tenderness and distress are frequently, but not con- 
stantly, present. They occur at all periods of the disease. They 

' "N". O. Med and Saxg, Jom-., toL L p. 299. 2 Ibid. p. 4i : . 

3 Louis on Yellow Fever, p. 22 9j et seq. 



SYMPTOMS.— URINE.— HEADACHE. 421 

are sometimes severe, but more generally moderate.^ Dr. Lewis, 
of Mobile, and Dr. John Harrison, of New Orleans, both speak of 
an exquisite tenderness of the epigastrium, occurring chiefly 
towards the close of fatal cases. Dr. Harrison says, — " The 
slightest attempt to press upon the parts is resisted by the patient 
"svith all the expressions of intense agony and horror." The same 
symptom is thus described by Dr. Ixush : — " The stomach, towards 
the close of the disease, was alfected with a burning or spasmodic 
pain of the most distressing nature. It produced, in some cases, 
great anguish of body and mind. In others, it produced cries 
and shrieks, which were often heard on the opposite sides of the 
streets to where the patient lay."^ Bally, and many others, 
mention the same symptoms.^ According to Dr. Rush, flatulence 
of the stomach is a very constant, and in many cases, a very dis- 
tressing symptom. 

Sec. V. — Urine. The urine seems to be, generally, but slightly 
or not at all changed ; at any rate, its alterations are accidental, 
and in no way characteristic of the disease. In a certain propor- 
tion of cases, precisely how large, I am unable to say, the renal 
secretion is wholly su*spended. This is more frequent in fatal 
cases, than in others, although it is not entirely confined to them.'* 
Bally says, that in the third stage of the disease the urine is very 
various in its appearance, — sometimes yellow, — sometimes red, or 
bloody, sometimes brown, black, fetid, and so on.^" 

ARTICLE III. 

CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. 

Sec. I. — Headache, and other local pains. Pain in the head is 
almost invariably present ; and it is nearly always the first, or one 
of the first, signs of the formal access of the disease. It is some- 
times slight, and at others moderate; but more generally, it is 
acute and violent. It is frequently felt through the temples and 

' Louis on Yellow Fever, p. 212, et seq. 

2 Rush's Med. Inq., vol. iii. p. 66. 

3 Du Typhus d'Amerique. Par Vr. Bally, p. 217. 
■' Louis on Yellow Fever, p. 235, et scq. 

5 Du Typhus d'Amerique. Par Vr. Bally, p. 244, 



422 TELLOvr jzm. 

ejebaHs. In a few cases, it continues through the whole course 
of the disease ; but, in most instances, it subsides in the course 
of two or thiee dajs. Pains in the back, loins, and limbs, are 
equaUj constant and equally severe; occurring usuaUj with the 
headache, or immediately following it, and subsiding in most cases 
with the latter. In some instances^ there are yicdent pains in tlie 
calves of the legs. Dr. Rush says. — • Tie back sufiered t; 
much, in this disease. The st: rs : :. lomplained, and e^ri: 



groaned under it. The symp 
of the ack extended to a smal 
not include their 5 feriLr? '- 
I ever lost by deai:. :.r ; i:t 



:::;:iiswith the distresses 
: : their misery, when it did 
^^' :: i of the dearest fiiends 
: : r gi: of her illness, that no 
one knew- the pains of a yeUow fever, but those who felt them.''^ 
Bally speaks part: . ^ ' ' e atrocious pain in the small of :1 r 
back, which acec ::^ : r first stage of the disease, as tie 

shadow feUows the substance.^ Dr. Lewis says, that females 
suffer veiy little firom pain in the head, while it is usually veiy 
severe in the ba(^ and hips ; and that some mothers complain of 
these pains as worse than those of parturition. In addition to 
these acute local pains, which are mostly confined to the early period 
of the disease, the subsequent stages of many cases are marked 
by an indefinite feeling of extreme restlessness, wretchedness, and 
distress, often manifesting itself in fits or paroxysms, with longer 
or shorter intervals of comparative ease. Dr. Lewis, in reporting 
a fatal case, has the following: — ''Being asked why he was so 
restle^, he replies, that he is not restless, neither does he feel 
very sick; at the same time, in a slow methodical manner, some- 
what peculiar to this disease, he removes the piQow to the other 
^de of the bed, and places his head upon it, with the same care 
and caution as thou^ it were a piece of ^ass. After a few 
minutes' conversation, the same preparations are being duly made 
for another change of position.''^ This paroxysmal restlessness 
attends the second and third stages of the disease, and constitutes 
one of its most constant and striking features. ** Jactitation," — 
says Dr. GiUkrest, — ** is of more frequent occurrence, and more 
severe in degree, than in any other disease, spasmodic cholera not 
excepted ; the patient toi^es his head and limbs about incessantly. 



M^d. Issq^ xdL ilL p. 66. 
2 Dei TjplHQs d'Amoiqpiie. Pfeir Vr. Baly, p. 225. 
» 35. O. Med. and Sons. Joar^ toL L p. 'im. 



SYMPTOMS.— MIND. 423 

unable to procure sleep in any position, or relief from the feeling 
of distress by which he is oppressed."^ 

Dizziness and giddiness are rarely mentioned by writers on 
yellow fever. 

Sec. II. — State of the Mind. Delirium is rarely present, ex- 
cepting for a short period, varying from a few hours to a day or 
two, preceding death ; it is very rarely wild and violent, and in 
many cases the mind remains clear, quite to the close of life. 
"In no other grave malady," — says Bally, — "do the intellectual 
faculties maintain themselves Avith such entire integrity as in this; 
it is a singular phenomenon, — that of the presence of mind pre- 
served to the last instant of life."^ 

Dr. Barrington says, there is often an inclination to sing; Dr. 
Lewis says, the delirium consists in joking, singing, or idle chit 
chat ; and Dr. Harrison speaks of the little tricks of the patients, 
the kind of perverse pleasure which they manifest in thwarting 
the designs of their nurses and physicians, and their great delight 
at the success of their schemes, as characteristic rather of a spe- 
cies of insanity, than febrile delirium. 

Our picture of yellow fever would be altogether imperfect and 
unfinished without the introduction of certain dark and fantastic 
shadows, which come in more appropriately here than anywhere 
else. To leave them out would be like omitting the grinning and 
horrible shapes from one of the witch scenes of Teniers. Dr. 
Barrington says, that amongst the United States sailors, the pitiful 
sighing and the indescribable restlessness of near dissolution w^ere 
frequently mixed up with obscene remarks and a desire for coition.^ 
In illustration of this monstrous perversion of an animal appetite, 
usually extinguished by violent acute disease, Dr. Lewis relates a 
case in the following words. "The subject w^as a man by the 
name of Nickols. He had had three paroxysms of fever; the 
fourth did not occur as usual, but the patient was restless and 
dissatisfied with everything. As this was the first case of black 
vomit that occurred in my practice this season, I did not suspect 
the true character of the disease, and permitted the patient to go 
three miles to a tavern in the country. On the morning of the 

' Cyc. Prac. Med., vol. ii. p. 270. 

2 Du T3T)hus d'Amerique. Par Vr. Bally, p. 211. 

3 Amer. Journ. Med. Sci., Aug. 1833. 



424 YELLOW FEVER. 

fifth day of Ms illness, I was summoned to him. The tavern in 
which he was lying was frequented by prostitutes, and as Nickels 
had been a gay Lothario, they had gathered around him in con- 
siderable numbers. He appeared to be in a joyous and mischiev- 
ous mood ; occasionally amusing himself by squirting the thin 
black vomit at such of the ladies as he did not fancy; and when 
successful in soilingr their clothes he would lausrh most immo- 
derately. After an hour had been thus consumed, he requested 
every person to leave the room with the exception of myself and 
his particular favorite. He now expressed a strong desire for 
sexual intercourse, and wished to know if I had any objection. I 
here examined him and found that this was not a inere whim, 
if physical signs at least were any evidence. I left the room, but 
the oirl soon came rushing: after me without havinsr yielded to his 
wishes. One hour afterward he was a dead man."^ 

The kind of stolid indifference of patients in this disease has 
often been noticed. The editors of the New Orleans Medical 
Journal say, — " It is remarkable to witness the indifference with 
which the victims of yellow fever in the Charity Hospital seem to 
view death. The large congregation of sick and dying seems to 
render them familiar with his face, and to rob him of more than 
half his terrors. After entering the hospital, and witnessing the 
d^-ing struggles of some half dozen or a dozen fellow-sufferers, 
they meet their fate with composure, and quietly resign a life 
which, perhaps, to many of them, had presented naught but a 
varied scene of toil and care."^ Dr. Rush, and Dr. Lewis, of 
Mobile, speak of occasional cases, not attended with delirium, 
in which the patients after recovery retain no recollection of what 
took place durins^ their illness. 

Coma is an uncommon symptom : but sometimes grave cases 
are marked by different degrees of drowsiness and stupor. The 
sleep is generally disturbed, and the patients often harassed by 
distressing dreams. 

Sec. m. — Physiognomy. The appearance of the face, and the 
expression of the countenance, have always been particularly 
noticed by observers of yellow fever. Dr. Rush says. — •' Upon 
entering a sick room, where a patient was confined by this fever, 

1 X. 0. Aled. and Siug. Jcurn^ vol. L p. 294. - Ibid., p. 77. 



SYMPTOMS.— PHYSIOGNOMY. 425 

the first thing that struck the eye of a pliysician was the counte- 
nance. It was as much unlike that which is exhibited in the 
common bilious fever, as the face of a wild is unlike the face of a 
mild domestic animal. The eyes were sad, watery, and so in- 
flamed, in some cases, as to resemble two balls of fire. Some- 
times, they had a most brilliant or ferocious appearance. The 
face was suiliised with blood, or of a dusky color, and the whole 
countenance was downcast and clouded."^ Mr. Pym says, it is 
impossible to describe the appearance of the face, but that those 
wishing to form an idea of it may see what he calls its fac-simile 
in the countenance of any person with a florid complexion, dur- 
ing the burning of spirit of wine and salt, in a dark room, as is 
practised in the game of Snap Dragon during the Christmas Gam- 
bols.- Dr. Lewis, of Mobile, says, — "The physiognomy of the 
disease is striking and peculiar. I have not noticed, how^ever, 
any of that wild, ferocious expression of eye and features, which 
is spoken of by many writers. There is usually an attempt, on 
the part of the patient, to appear amiable and indifferent, seldom 
becoming peevish, or losing temper. The expression of which 
I am speaking is, in many cases, stamped upon the brow, at an 
early period; and, *once enthroned,' no effort of the patient can 
disturb its reign ; — he may smile and laugh, but he cannot chase 
it away; there it still sits, mocking the assumed gayety and levity 
of its victim. Even the cradle is not exempt from its visitations ; 
within the last hour, I have seen a child, but fifteen months old, 
over whose brow, this mysterious fiend has spread its gloomy 
mantle, giving to the little patient a dejected, cheerless, and 
earnest look, ill suited to its infant face.^" 

Dr. John ^Yilson, in a report of a case of w^hat he calls apo- 
plectic congestive yellow fever, speaks of a peculiar smile seen at 
times on the patient's face, and then adds in a note: — "It would 
be difficult to give a just notion of this peculiar smile to a person 
who has not seen it. Unlike the smile of health and happiness, 
it is confined to the mouth ; the face generally, and the eye in 
particular, having no share in its expression, but rather counter- 
acting or contradicting it, by their fixedness and despondency: 
neither has it any of the hideousness and distortion of the risus 
Sardonicus. It is a quiet, transient, smiling movement of the 

* Rush's Med. Inq,, vol. iii. p. 52, 2 Pyi-n. upon Bulani Fever, p. 5. 

3 N. 0. Med. and Surg. Journ., vol, i. p. 299. 



426 YELLOW FEVER. 

lips alone, melancholy in itself, and by contrast with the general 
aspect ; and rendered more melancholy, by being associated with 
apprehensions of a fatal issue; for in my observation it has always 
been the forerunner of death. "^ 

The redness and suffusion of the eyes, so striking in this dis- 
ease, and noticed by nearly all writers, have been particularly de- 
scribed by Louis. He found them in all cases, the mild as well 
as the severe; and they were generally present at the commence- 
ment of, or early in, the disease. In cases terminating fatally, 
the redness of the eyes sometimes continues undiminished to the 
close of life ; more generally, it becomes less intense, or disap- 
pears, before death. In cases terminating in recovery, it disap- 
pears with convalescence, and the patient's restoration to health. 
In most instances, the redness had a double character, — a uniform, 
delicate, rose tint, as if put on with a brush ; and a more or less 
marked injection of the vessels of the conjunctiva. "In the cases 
where the redness had not disappeared at the time the yellowness 
came on, the mixture of yellow and red in the sclerotic was very 
remarkable. The eyes were usually more or less glistening, moist 
and suffused, frequently sensible to the light, but rarely what may 
be called painful."^ Sir Gilbert Blane says, — "There is some- 
thing very peculiar in the countenance of those who are seized 
with this fever, discernible from the beginning, by those who are 
accustomed to see it. This appearance consists in a yellow or 
dingy flushing or fullness of the face and neck, particularly about 
the parotid glands, where the yellow color of the skin is commonly 
first perceived. There is also in the eye and muscles of the 
countenance a remarkable expression of dejection and distress."^ 

Sec. IV. — Strength; Muscles; Senses. In a certain proportion 
of cases, there is more or less loss or prostration of muscular 
strength. Sometimes, and especially when there is much hemor- 
rhage, this may be extreme ; but it is more commonly only mo- 
derate, and, in many instances, it is absent to a very striking 
degree. Dr. Rush says, — "Patients in the close of the disease 
often rose from their beds, walked across their rooms, or came 
down stairs, with as much ease as if they had been in perfect 

^ Memoirs of the West Indian Fever, p. 57, 

2 Louis on Yellow Fever, p. 200. 

3 Obs. Dis. Seamen, p. 400. 



SYMPTOMS. STRENGTH.— MUSCLES.— SENSES. 427 

health. I lost a patient in whom this state of morbid strength 
occurred to such a degree, that he stood up before his glass, and 
shaved himself, on the day upon which he died."^ These are 
called walking cases by the physicians of our southern cities.^ 
Although they are exceedingly grave in their character, almost 
always terminating fatally, they are not generally marked by the 
usual symptoms of the disease. There maybe no chill, no fever, 
no local pain; and the tongue, pulse, and skin are nearly natu- 
ral. These singular latent cases are noticed also by Louis. "It 
is under this form of the disease," — he says, — " that patients died 
w^ithout taking to their beds, — on foot, — as it was expressed by 
their friends. Thus, Dr. Mathias, who died after an illness of 
four or five days, experienced no other symptoms but severe pains 
in the calves of the legs, and a suppression of urine. He had no 
nausea; he did not vomit. His mind was perfectly clear, during 
the whole course of the disease; he noticed the continuance of the 
suppression of urine, dictated three or four letters to a friend, 
begged him to write rapidly the last, so that he might sign it, then 
devoted a little time to an affectionate intercourse with this friend, 
and soon after, unable to speak, he thanked the friend by a sign, 
and in a quarter of an hour he was dead."^ " I have known a 
man," — says Dr. John Wilson, — " in cases like these, ordered to 
do his duty, because the surgeon could not perceive much the mat- 
ter with him; he continued to do his duty, after a fashion, for 
nearly two days, when the eruption of hlack vomit gave irresisti- 
ble and mortifying evidence that the man was no impostor."^ 
Spasmodic contractions of the muscles are of rare occurrence ; 
excepting, however, those of the diaphragm, constituting hiccough. 
This is a frequent and very sure precursor of death. 

The senses are generally free from any considerable disturb- 
ance. Slight intolerance of light is not unfrequently present. The 
hearing is unimpaired, and there is not often any ringing in the 
ears. 

* Rush's Med. Inq., vol. iii. p. 64, 

2 This term is said to have been first applied to these cases by Professor Cald- 
well, now of Louisville, Kentucky. 

^ Louis on Yellow Fever, p. 170. 4 Memoirs of the West Lidian Fever, p. 15. 



428 YELLOW FEVER. 

ARTICLE IV. 

MISCELLANEOUS SYMPTOMS. 

Sec. I. — Color of Skin. Yellowness of the surface of the body 
is almost always present in fatal cases ; occasionally, it is wanting. 
Sometimes, it appears early in the disease ; but, in most instances, 
not till about the middle period, or later. The yellowness is often 
deeper on the chest than upon other parts of the body; and it is 
frequently preceded by a more or less vivid redness and injection 
of the integuments. It usually shows itself first on the conjunc- 
tiva, and round the border of the chin, then extending to the chest, 
and afterwards over the body. In mild cases, and in those ter- 
minating in recovery, this symptom is very frequently absent. 
Dr. Bancroft says, — " The yellowness is sometimes of a dingy or 
brownish hue, sometimes of a pale lemon, and at others, of a full 
orange color. "^ Dr. Gillkrest says, the yellowness may be par- 
tial, or general, and may vary from the light lemon color to deep 
ochre yellow.^ Dr. John Wilson says, the discoloration of the skin 
differs in the two forms of the disease, — the inflammatory, and the 
congestive. "In the former, the skin is yellow, of different shades 
in different instances. Sometimes it is light, sometimes dark ; 
sometimes it is of the color of an unripe lime, sometimes of a mel- 
low orange; varying constantly, and being scarcely the same, in 
every respect, in any two cases : still it is yellow, and would be 
instantly pronounced so by all observers; though, in endeavoring 
to describe its exact tinge, different words would be employed by 
different persons, sometimes inappropriate ones, and erroneous 
opinions would thence be formed. * * * In the congestive form, 
the skin is discolored, but does not become yellow. Its color is 
not like that of an icteric patient; it may rather be called pete- 
chial, as it resembles, though it is not exactly like, the skin of 
persons in the last stage of what is called putrid fever. From the 
first the skin loses its proper lustre. It becomes blanched, or 
lurid ; and as the disease advances, livid and black patches of 
various sizes are observed on the breast, back, hips, scrotum, and 
extremities. They pervade the surface, but are most numerous 
generally on the trunk. About their margins there is a yellowish, 

' Bancroft's Essay, p. 34. 2 Cyc. Prac. I\Ied., vol. ii. p. 27.3. 



SYMPTOMS.— HEMORRHAGES. 429 

or greenish hue, either of them indistinct, and what is called dirty. 
It is difficult to describe the aspect of the skin accurately and in- 
telligibly; but, by comparing it with a familiar object, which it 
very closely resembles, a pretty correct notion of its peculiarities 
will be obtained. When yellow leather gloves are w^orn on horse- 
back, in rainy weather, and the glove of the bridle hand is tho- 
roughly w^et, the palm part of it exhibits a very just likeness of 
what I have attempted to delineate, — turbid white, and livid or 
black, intermixed with imperfect margins of yellow^ and green, or 
a hue in which yellow and green are blended, and it is difficult 
to say w^hich predominates. This appearance of the skin in the 
congestive form, and the yellowness w^hich I have appropriated to 
the inflammatory, I am persuaded, are characteristic of each re- 
spectively ; but I am not from my experience justified in saying 
they are so absolutely, and without any exception."^ 

Sec. II. — Hemorrhages. Nearly all writers upon yellow fever 
speak of the frequency of hemorrhages from different parts of the 
body. Dr. Rush, after mentioning the occasional occurrence of 
bleeding from the nose, and from the uterus, in the early period 
of the fever, says, — " As the disease advanced, the discharges of 
blood became more universal. They occurred from the gums, 
ears, stomach, bowels, and urinary passages. Drops of blood 
issued from the inner canthus of the left eye of Mr. Josiah Coates. 
Dr. Woodhouse attended a lady who bled from the holes in her 
ears, which had been made by ear-rings. Many bled from the 
orifices w^hich had been made by bleeding, several days after they 
appeared to have been healed. These last hemorrhages were very 
troublesome, and, in some cases, precipitated death. "^ Similar 
bleedings are spoken of by other writers, from bHstered surfaces, 
from the scrotum, from the uterus, from mosquito bites, from leech 
bites, and so on. They take place more frequently from the gums 
and tongue than from any other part of the body; and there is 
good reason for believing, that these last are occasioned, in part 
at least, by the action of mercurials. Hemorrhages are more com- 
mon in the latter stages of grave cases, than under other circum- 
stances ; and they seem to be more general in some seasons and 
places than others. By many pathologists, the matter of black 

1 Memoirs of the West Indian Fever, p. 22. 

2 Rush's Med. Inq., vol. iii. p. 57. 



430 YELLOW FEVER. 

vomit, and of the black stools, is considered to be the result of a 
true hemorrhage from the gastro-intestinal mucous surface. 

Sec. ni. — Chest. The symptoms connected with the lungs 
are quite unimportant and accidental. There is no cough, and 
there are no morbid rhonchi. The breathing in the late stages of 
grave and fatal cases is not unfrequently more or less deep, and 
sighing. I do not know that the action of the heart has been 
particularly studied. 



431 



CHAPTER III, 

ANATOMICAL LESIONS. 
ARTICLE I. 

LESIONS OF THE LUNGS, HEART, AND BLOOD. 

Sec. I. — Lujigs. The condition of these organs, so far as I 
know, has been particularly and carefully studied, only by Louis 
and Trousseau ; and in fifteen cases, they found them the seat of 
lesions, which seem to have been very rarely met with, in any 
other disease. These lesions consisted of black spots of from two 
to five lines in diameter ; or of masses of the same color, more or 
less impermeable to the air. The spots were found in nine sub- 
jects. In a few cases, they were of a crimson hue ; but, gene- 
rally, they were brown or black. They were more or less crowded 
together, occupying a space of variable extent on the surface or 
in the interior of the lung; in some cases, they were found only 
in the lower lobe. The density of the tissue which was the seat 
of them was not manifestly increased, except in two cases ; this 
increase of density was evidently the result of an effusion of blood, 
more or less intimately combined with the pulmonary tissue. 
" The black or blackish masses existed in six individuals; their 
consistence was greater or less ; they contained no air ; they had 
not the granulated aspect of hepatized lung; they presented but 
slight traces of organization, so that merely some cellular fibres 
irregularly disposed could be distinguished in them. Usually, 
they could be easily broken down ; in some cases, also, they 
yielded by pressure the blood of which they were almost entirely 
composed, and the pulmonary parenchyma remained apparently 
of its natural consistence. In one case it was impossible to re- 
move the blood by a gradual and moderate pressure, and here the 
tumor or mass was as large as the fist, had more cohesion than 
the parts in the second degree of pneumonia, and less than the 



432 YELLOW FEVER. 

parts in the state which the illustrious Laennec has designated as 
pulmonary apoplexy. The same was true in another subject, in 
whose lungs we found from twenty-five to thirty tumors of this 
same character, though of a little different aspect, and somewhat 
resembling the thyroid gland. Their structure was apparently 
homogeneous, quite friable, and as in the other cases, there was no 
line of demarcation between them and the pulmonary tissue." 
I do not know whether it was this lesion of the lungs that was 
noticed by Arejula at Cadiz in 1800. He says, — "On opening 
the cavity of the thorax, the lungs appeared speckled with black 
and gangrenous spots, which were particularly observed in those 
bodies in which the disease had assumed the most malignant form.^ 
Mr. M'Colme says, " the lungs were often blackish, next the 
pleura, and interspersed, in many places, with large livid spots. "^ 
Dr. Deveze seems to have studied the anatomical lesions of yellow 
fever, during the Philadelphia epidemic of 1793, with more zeal 
and carefulness than any other physician. He does not state the 
number of his autopsies, but he reports in detail eight examina- 
tions which he made at the Bush Hill Hospital. The lungs, he 
says, were sometimes found healthy ; but more frequently they 
were flabby, covered with black spots, engorged with blood of the 
samie color, and so on. He quotes other observers who had no- 
ticed black and gangrenous spots on the surface of the lungs.^ 
O'Halloran did not notice any special alteration of these organs. 
Louis and Trousseau found, in several cases, a livid color of the 
air passages, more or less vivid, occupying the mucous, and the 
sub-mucoQS, cellular tissue. Other lesions of the lungs and 
pleur3S are of very rare occurrence.'^ 

Sec. II. — Heart. Louis and Trousseau found the heart soft, or 
flabby, or both soft and flabby, in a considerable proportion of 
cases. Other changes in this organ, and in the aorta, are acci- 
dental merely, and such as are frequently found after death from 
acute disease. Deveze found the heart flabby, pale, and very 
soft.^ 

Sec. III. — Blood. The blood found in the cavities of the heart, 

1 Reports, etc., by Sir J. Fellows, p. 68, 2 Hunter"s Dis. of Army, p. 161. 

3 Traite de la Fievre Jaune. Par Jean Deveze, p, 62. 

4 Louis on Yellow Fever, p. 63, et seq. 6 Rush's Med. Inq.. vol. m. p. 92. 



LESIONS —BLOOD. 433 

and In the large vessels, after death, seems to be very generally- 
changed from its natural condition. This change was noticed by 
the older observers ; and it has been more particularly studied in 
our own time. Dr. Physick and Dr. Cathrall say, — "The blood 
in the heart and veins is fluid, similar, in its consistence, to the 
blood of persons who have been hanged, or destroyed by electri- 
city.^ Hillary speaks particularly and repeatedly of the state of 
the blood. " E\«n at the beginning of the disease," he says, — 
" it is often of an exceeding florid, red color, much rarefied and 
thin, and without the least appearance of siziness; and the cras- 
samentum, when it has stood till it is cold, will scarce cohere, but 
fluctuates."^ Louis and Trousseau found the blood generally 
either liquid only, or liquid and clotted ; the clots being black, or 
yellow, and fibrinous. Dr. Nott, of Mobile, gives the following 
interesting account of the blood in the cases examined by him, in 
1843, and 1844. "This was found dark and fluid in every case 
where the bodies were opened. Minute observations were not 
made, in all the cases, but in about one-half, the blood was col- 
lected by thrusting a trocar into the right auricle, and drawing it off 
into clean quinine bottles. It w^as so fluid, and was accumulated 
in such quantity in the auricle and veins connected with it, that 
ten or twelve hours after death, it w^ould run freely through the 
canula, to the amount of a pint or more. When set aside, it 
coagulated at intervals, varying from fifteen or twenty minutes, to 
thirty-six hours ; the clots were soft, grumous, easily broken down, 
showing a great deficiency of fibrine, and corresponding with 
Andral's description of the blood in the other pyrexiae. In one 
case, it did not coagulate at all, but presented a true state of dis- 
solution."^ Dr. Harrison says, it requires a much longer time 
for the blood to coagulate, than in other diseases, and that the 
coagulum is large and soft ; he adds, that it rarely presents the 
buffy coat when drawn from the arm, and that he has never seen 
it cupped. "* 

' Rush's Med. Inq., vol. iii. p. 92. 2 Rush's Hillary, p. 108. 

3 Amer. Jour. Med. Sci., April, 1845. 

* N. 0. Med. and Surg. Jour., vol. ii. p. 140. 

28 



434 YELLOW FEVER. 

ARTICLE II. 

LESIONS OF THE CEREBRO-SPINAL APPARATUS. 

There are no alterations of this apparatus, excepting such as are 
frequently found after death from other acute diseases. These 
are moderate effusions of serum in the sub-arachnoid tissue, and 
into the cavities of the brain; a more or less redf or violet, or lilac, 
color of the cortical substance, and occasional slight injection of 
the medullary portion of the brain. 

ARTICLE III. 

LESIONS OF THE ABDOMINAL ORGAN'S. 

Sec. I. — Stomach. The mucous membrane of the stomach is 
more or less altered, in a pretty- large proportion of cases. Louis 
and Trousseau found it of natural thickness, consistence, and 
aspect, with the exception only of slight changes of color, in five, 
of twenty-three, cases; in the remainder, it presented evident 
traces of previous inflammation. Its color was quite natural, in 
only three cases ; in several, it was more or less deeply red, some- 
times over its whole surface, and at others only over circumscribed 
portions ; in eight cases, instead of a red color, there was an orange, 
or a slight, rose tint, or a color of onion parings, varying in ex- 
tent; in two cases, there was a ruddy or bistre hue, and in two 
others, the membrane was greenish or yellowish. The thickness 
of the membrane was natural, in half the cases; in the other half, 
the thickness was increased ; — in some universally, and in others 
partially. Its consistence v^diS natural, in only two subjects; in 
all the rest, it was more or less diminished. The softening was 
general, but moderate, in five ; partial, and but rarely to a remark- 
able degree, in the others, so that in no region, not even in the 
great cul-de-sac, was the membrane reduced to the consistence 
of mucus. Well marked and more or less extensive mamellona- 
tion was found in two-thirds of the subjects; and it is important 
to remark, that this lesion was always accompanied by thickening, 
or softening of the membrane, or by both, and by alterations of its 
color. Dr. Ashbel Smith has published a history- of the appear- 
ance of the abdominal orsrans in seven cases of yellow fever, 



LESIONS.—STOMACH.— CONTENTS. 435 

occurring in Galveston, Texas, in 1839. He found the mucous 
membrane of the stomach of a whitish pearl color, much thick- 
ened and softened. In four cases, these lesions were limited to 
certain portions of the membrane, while the remaining portion, 
in the cardiac extremity, was the seat of a very intense, uniform, 
red injection, but was neither thickened nor softened.^ Subse- 
quent observations, by other physicians, have led to the same 
general results, in regard to the condition of the stomach. Dr. 
Josiah C. Nott, of Mobile, in sixteen cases, examined in 1843, 
and 1844, found the mucous coat of the stomach free from any 
appreciable change in seven; in the remaining nine, it was more 
or less reddened, softened, thickened, and mamellonated.^ 

The contents of the stomach are thus minutely and particularly 
described by Louis. In four subjects, the stomach contained only 
a small quantity of flocculent mucus, or a little grayish, yellowish, 
or dark-colored, liquid ; in all the others, eighteen in number, the 
contents of the stomach were red, more or less inclining to black. 
This red or black matter varied in quantity, from four to twenty 
ounces ; and its quantity was in proportion to the depth of the red 
color; the mean quantity where the color was bright red being 
nine ounces, and fourteen ounces where it was entirely black. 
The consistence of the red and the black matter was about the 
same; in some, it was quite liquid, in others, it was like porridge. 
It separated, on standing, into tw^o portions; the upper more liquid 
than the lower, and of a bistre color; the lower less abundant and 
formed, as it w-ere, of blackish parcels.^ This matter of black 
vomit was formerly supposed to be derived principally from the 
liver, and to consist of vitiated bile, mixed with the fluids of the 
stomach. Dr. Rush says, that he at one time believed this mat- 
ter to consist of vitiated bile, but that subsequent dissections by 
Dr. Stewart, and Dr. Physick, convinced him that it was derived 
from the stomach; although I find in the report of the dissections, 
made by Dr. Physick and Dr. Cathrall, and quoted by Dr. Rush, 
the black liquor, found in the stomach and intestines, referred to 
an altered secretion from the liver. This opinion is now, I think, 
generally, if not universally, abandoned; and it seems to me quite 
clear, that the matter of black vomit consists of blood, mixed with 
the fluid secretions of the stomach, and derived directly from the 

> Amer. Jour. Med. Sci., Feb., 1840. = Ibid., April, 1845. 

3 Louis on Yellow Fever, p. 79, et seq. 



436 YELLOW FEVER. 

mucous membrane. Dr. Nott, and Dr. P. H. Lewis, of Mobile, 
have made some interesting experiments for the purpose of ascer- 
taining the nature of this substance. Dr. Nott believes it to con- 
sist of blood, exhaled in its natural state from the capillaries of 
the stomach, intestines, and even the bladder, and changed black 
bv the secretions with which it comes in contact; this chemical 
chancre being produced by one or more acids. He says, that the 
matter of black vomit is always acid, turning litmus paper red ; 
and he supposes, that the acrid property of the liquid may depend 
upon the presence of these acids. Dr. Nott found, further, that 
the matter of black vomit can be very exactly imitated, by adding 
to a few drachms of blood, four or five drops of muriatic acid, and 
a little gum water, or flax seed tea, to represent the mucus of the 
stomach. No one can distinguish, he says, the artificial from the 
natural black vomit; although he admits that the small coffee 
grounds coagula are more difficult to imitate. A very small 
quantity of blood, he thinks, oozing, gradually, in a minutely 
divided form, and mingling slowly with the secretions of the 
mucous membrane of the stomach and bowels, will make a large 
quantity of black vomit. ^ The opinion, that the coloring matter 
of black vomit consists of blood, is strengthened by the fact that, 
in some instances, pure blood is found in the stomach. It is pro- 
bable, that, as a general rule, this matter is derived exclusively 
from the mucous surface of the stomach, and not from that of the 
intestines ; although the observations of Louis lead to the conclu- 
sion that it may sometimes be furnished by the latter. It is im- 
portant that a single additional remark should be made here. 
We have no right to assume, that the appreciable, inflammatory 
lesions of the stomach are the essential cause and condition of the 
presence of the matter of black vomit ; and this for the obvious 
reason, that the latter is not unfrequently found where the former 
do not exist. All that we can do, in the present state of our 
knowledge, is to refer the productions of this substance to some 
special but unascertained pathological action or condition of the 
mucous membrane of the stomach, or of the fluids of the body; 
or, as is more probably true, of both ; the inflammatory lesions of 
the gastric mucous membrane being also one of the results and 
complications of this same action or condition.^ 

* Amer. Jour. Med. Sci., April, 1845. 

2 The true character and origin of the matter of black vomit were clearly stated 



LESIONS.— STOMACH.— INTESTINES. 437 

As to the nature of these lesions of the stomach, it seems to me 
there can be no reasonable doubt. Where they are well marked, 
and especially where the membrane is reddened, soitened, and 
mamellonated, we are obliged to consider them the result of in- 
flammation. If we refuse to do this, merely because some of the 
ordinary phenomena of simple, acute gavStritis are wanting, there 
is at once an end to all rational or positive conclusions. At the 
same time, it must be admitted, that the inflammation of the gas- 
tric mucous surface is a peculiar or specific inflammation ; it is, 
in some way, modified by the general disease ; it derives from the 
latter some special and unknown element, w'hich does not exist 
in other forms of gastritis, whether these latter are primary or 
secondary. 

Dr. Ashbel Smith concludes from his observations, that the 
softened, thickened, and mamellonated condition of the membrane 
is always preceded by an intense sanguineous engorgement, dif- 
fering in its nature from inflammation, and resulting in the pro- 
duction of the matter of black vomit, and the lesions of the mem- 
brane which it precedes.^ 

Ulceration is of very rare occurrence. In regard to the volume 
of the stomach there is nothing constant: sometimes it is con- 
tracted, sometimes distended, and at others natural. 

Sec. II. — Intestines. The mucous membrane of the small in- 
testines is, in a considerable number of cases, quite natural 
throughout its whole extent ; or it is the seat only of slight and 
unimportant alterations. Its thickness and consistence are rarely 
changed ; in a certain proportion of cases, there are patches, or 
sections, of redness, mostly within a few" feet of the coecum. 

a long time ago. Dr. Bancroft quotes Dr. Henry Warren, who wrote on the yellow 
fever of Barbadoes, in 1740. Dr. Warren says, — "I ought here to observe, that the 
fatal black stools and vomitings are vulgarly supposed to be only large quantities 
of black bile, or choler; which false notion seems to be owing to that fixed unhappy 
prejudice, that the fever is purely bilious. But let any one only dip in a bit of white 
linen cloth, he will soon be undeceived, and convinced, that scarce any thing but 
mortified blood is then voided, for the cloth will appear tinged of a deep bloody red, 
or purple, of which I have made many experiments." — Bancrofts Essay, p. 28. Sir 
John Pringle, Dr. John Hunter, and Sir Gilbert Blane, .amongst others, entertained 
similar views. Mr. Pym says he is convinced that the matter of black vomit is 
blood in a dissolved state, poured forth from the small vessels, abraded by the sepa- 
ration or disease of the villous coat, and acted upon by the gastric fluid. 
» Amer. Jour. Med. Sci., Feb., 1840. 



438 YELLOW FEVER. 

Redness, softening, and thickening of the lining of the large 
intestine are more frequent. Louis and Trousseau found uni- 
yersal softening in fourteen of twenty-three cases. The latter 
lesions are probably the result of inflammation. 

The upper portion of the small intestine usually contains the 
same kind of reddish, brownish, or blackish matter that is found 
in the stomach ; and the same substance is found also in the large 
intestine.^ It is thicker and more consistent, especially in the 
laro-e intestine, than it is in the stomach. Pure blood has occa- 
sionally, though rarely, been found both in the stomach and 
bowels. The volume of the intestines is not often altered. 

Louis and Trousseau found the epidermis, which lines the 
oesophagus, perfect in only five cases ; in all the others, it was 
more or less completely destroyed.^ Dr. Nott of Mobile, thinks 
it probable, that this destruction of the epidermis of the oesopha- 
gus depends upon the acid acridness of the matter of black 
vomit.^ 

Sec. IIL — Liver, Since the publication of the researches of 
Louis and Trousseau upon the yellow fever of Gibraltar, in 1828, 
the attention of pathologists has been turned, particularly, to the 
condition of the liver in this disease ; and the resiilt of subsequent 
observations in regard to the state of this organ in periodical, or 
marsh fevers, has imparted to the subject new interest and im- 
portance. The following, I believe, is a full and fair summary 
of the present state of our knowledge in relation to this question. 

Louis and Trousseau, in all the subjects examined by them, at 
Gibraltar, found a very striking and uniform change in the color 
of the liver. They describe the liver as being sometimes of the 
color oi fresh butter; sometimes of a straw color; sometimes 
of the color of cqfee and milk; sometimes of a yellowish gum 
color, or a mustard color, and, finally, sometimes of an orange or 
pistachio color. " This discoloration," — they say, — " was not the 
same throughout the whole extent of the liver ; more marked in 
the left than in the ri^ht lobe ; it was also more uniform. In cases 
where the color was uniform in the left lobe, there was in the 
right lobe a mixture of gum yellow, orange, or red points, larger 
or smaller; or else we found in the right lobe a rose tint, which 

i Amer. Jour, of Med. Sci., Feb., 1S40. 2 Loiiis on Yellow Fever, p. 100. et seq. 
* Nott oa Path, of Yellow Fever. 



LESIONS.— LIVER. 439 

did not exist in the left lobe. The cases in which the color of 
the liver was formed by the mingling of ditierent colored points 
were rare; and this disposition was somewhat remarkable in one 
of them, where the liver presented a mixture of yellow and green 
points. This change of color extended throughout the whole of 
the organ, in all but three cases ; in these, it was limited to the 
left lobe, or to the left and a part of the right, the latter preserving 
its natural color throughout, or in its obtuse edge only." 

" With the discoloration of the liver, are found a more or less 
marked paleness, and a diminished quantity of blood, so that 
wherever this appearance of the liver was well marked, the sec- 
tions of it were dry, and of an arid appearance in the left lobe. 
This appearance reminded us at first of the greasy transformation 
of the liver, a transformation always accompanied by a softening, 
more or less marked. In the cases now^ under consideration, the 
cohesion of the liver was not at all diminished, even where the 
organ was of a clear coffee and milk color, or of a straw yellow, 
or of the color of sole leather."^ The cohesion of the liver, and 
the resistance of its tissue to the knife, or to the hand, on attempt- 
ing to break it, were increased in five cases, and diminished in 
five others. 

The singular change in the color of the liver, thus particularly 
and specially studied by Louis and Trousseau, is regarded by the 
former as the characteristic anatomical lesion of yellow fever, — the 
only lesion constantly found after death from this disease. Louis's 
conclusion, so far as his own facts are concerned, and he carries 
it no further, is legitimate ; but these facts were not sufficiently 
numerous and various, finally and definitively to determine the 
question. These facts w^ere gathered in a single locality, and 
during the same epidemic season ; and although analogies drawn 
from some other forms of fever, and especially from typhoid, might 
seem to favor the probability, or, in some degree, to justify the 
conclusion, that this lesion of the liver would prove to be constant 
and characteristic, still such analogies are never to be trusted, and 
the settlement of the question must be referred to further and more 
extensive observations. But before giving the results of these 
observations, so far as they have yet been made, it may not be 
wholly without interest to notice some of the allusions to the con- 

* Louis on Yellow Fever, p. 117, et seq. 



440 



£:::_ -„;:/. :" r;:^ 5 " :i:5 :ii:.^z :: ::.:: i:: :.:: rMirety 



says 






desoibe tiT 
CGUTex an .: : 
on culting . T _ 
^«difHii JoLn I- - : 
idio senred as a 
jeais 1741 : r " 1 

three office: 5 i^ 
Ids letter in it 
in pait, ar_ : n 
hardikaai : 
^ ftl^iod tn 

Dr. Burn 
was of a - / 
accounl of 
Ktct was : 1 

Mr. I::--;-:-: 
diasec : r :1 

theKT 
Ibe €€.:: i 









■ • - - ' - ■ — 


T .._;_: -- — - —Z^ 


_ and in 


.^ IFgea!?-. -w^ i p. ISiL 


: ; : :" .-.J--J-, jiu SOL 



LESIONS.— LIVER. 441 

one, as a light yellow.-^ Dr. Hume made some examinations be- 
fore the middle of the last century. He says, — " The liver, which 
is naturally of a dark red color, frequently appears, on dissection, 
in the yellow fever, to be pale and ycUoioy^ 

The observations of O'Halloran upon this point, made in 1821, 
are very interesting. In his first reported case, the liver is de- 
scribed as extremely yclloiu externally, hard and dense when cut 
into; the flow of blood inconsiderable; — in the second, the liver 
was yelloiVf hard, and deficient in blood; — in the third, hard and 
yellow, loithout blood; — in the fourth, thick, hard, compacted, dry 
and pale, with no flow of blood lohen cut into, and crumbling be- 
tween the fingers ; — in the fifth, pale externally, hard to the feel, 
internally destitute of blood, and gntty, so as to be easily crum- 
bled into small pieces ; in the sixth, large and hard, crumbling be- 
tween the fingers ; in the eighth, pale yellow externally, internally 
hard, destitute of blood, and easily broken into small pieces ; — and 
in the ninth, considerably enlarged, hard and yellow externally, in- 
ternally destitute of blood, and easily crumbled. In three cases, it 
is described as either healthy, or inflamed. He quotes a letter 
from Dr. Salvador Campany, who says, — " The liver presented a 
saffron color, sometimes with obscure stains in its concave part."^ 

Dr. Nott, of Mobile, in his interesting paper on the Pathology 
of Yellow Fever, describes the liver, as it appeared in sixteen 
cases of the disease. Of eight cases examined during the epi- 
demic of 1843, the livers in two only corresponded with the de- 
scription of Louis, being pale, and when torn resembling, very 
closely, ginger bread, or new leather ; in the six others, the liver 
was of a dark blue or a dark chocolate color, presenting different 
shades, and excessively engorged with blood. Of eight cases 
examined in 1844, the liver in four corresponded w^ith the de- 
scription of Louis ; in two, the color was a dark olive, and in 
two, there was no alteration. Dr. Nott says, further, that he has 
twice met with the straw-colored liver after death from other dis- 
eases."* 

Dr. John Harrison, in his Remarks on the Yellow Fever of JYew 
Orleans, says, — "The liver sometimes contains less blood than 
we usually find in the viscus, and, in those cases, it is paler and 

• Doughty, p. 145. 2 Currie's Dis. of America, p. 57. 
3 O'Halloran on Yellow Fever, p. \S6, etseq. 

* Amer. Journ. Med. Sci., April, 1845. 



442 YIXI,OW FEYER. 

drier than nsnal. At otiier times, toweTer, it is engorged with 
blood, and hleeds freely vLen cut ; but these appearances it is 
subject to in common with all the organs, and the existence of one 
or the other, appears to depend much upon the condition of the 
patient at the time trfthe attack, and the treatment he has nnder- 
gDne. In cases where the lancet has been nsed freely, we shall 
generaHj find 2. pale yellow liver. '^'^^ The interests of science not 
only justify here, as in all similar circumstances, but they demand 
a single criticism. Where results merely are griven, — and these 
only in general terms, — where cases of disease are observed in a 
hospital, by extensire practitioners, constantly and busily occn- 
pied with their prirate practice, and where these cases are not 
reported in detail, there mnst inevitably occur, and this not nn- 
freqnently, errors of diagnosis. That this error was sometimes 
committed in the Charity Hospital, no one can for a moment donbt 
who reads the following statement by Dr. Harrison. He says, — 
** Jti sorne cases of a low typhoid type, in which there existed 
before death a low Jiervous delirium, we found, sometimes ulcera- 
tion, and at others hypertrophy and softening of Peyer's glands."^ 
These were unquestionably cases of true typhoid ferer ; such at 
any rate is the conclusion which, in the absence of any detailed 
histories of the cases themselves, we are justified in adopting : and 
if, under such circumstances, cases of typhoid fever could be con- 
founded with those of ydBow fever, how much more readily might 
this happen with tTte more di^ely allied forms of periodical feoer, 
— bilious remittent, and congestive. In the Gibraltar epdeoiic cf 
1828, a case was reported t© Louis, by Mr. Frazer, as one offei- 
low fever; where the yellow liver was wanting, and in which 
there was ulceration of Peyer's glands. A careful study of the 
case shows manifestly that there had been an error of diagnosis, 
and that the disease was typhoid, and not yellow, fever.^ In 
regard to the causes and nature of this peculiar condition of the 
liver, it is quite idle to speculate. We can only call it peculiar, 
or special, and plainly and frankly admit that we know little more 
about it. Clearly enough, it is neither inflammatory, nor con- 
gestive ; and this is about as far as we can go. It constitiites 
one of the pathological elements, — a very common though BOt at 
constant one, — in a specific disease, the result of a specific cause, 

1 K 0. Med. and Snrg. Jonm^ voL iL p. 136. « SadL, p. 139. 

* Lonis oil Yellow PeTer. p. 124. 



LESIONS.— GALL-BLADDER.— CONTENTS. 443 

the nature and action of which are yet hidden in absolute dark- 
ness. 

Dr. Richard D. Arnold, of Savannah, has reported a case of 
yellow fever in the American Journal of the Medical Sciences, 
for October, 1842. The liver was pale and ash colored on its 
entire surface, and throughout its whole structure; and it was 
very destitute of blood. Dr. Arnold says, — " Dr. Waring, in 
1827, pointed out to me, in the dead body, as the peculiar cha- 
racteristics of yellow fever, the pale appearance of the liver, its 
deficiency of blood, amounting to a comparative dryness, and the 
entire absence of all biliary secretion. Dr. Barrington, in his 
account of yellow fever, on board United States' vessels in and 
near the Gulf of Mexico, in 1828, 1829, and 1830, speaks of the 
liver in two cases as of a light color ^ Dr. Ashbel Smith made 
seven autopsies at Galveston, Texas, in 1839. In three cases, 
the liver was of a very light drab color, externally and internally, 
and destitute of blood ; in one, of a dark claret color, and con- 
gested with blood; in the others, of its usual appearance, and 
containing a moderate quantity of blood. In all cases, there 
appeared to be a suspension of the biliary secretion ; no bile could 
be squeezed from the substance of the liver. ^ M. Catel says there 
were one hundred and fifty yellow fever autopsies, at the Hospital 
of St. Pierre, in xVIartinique, between October, 1838, and Sep- 
tember, 1839; and that the liver was always deprived of its color 
— decolore — and yellow; and the gall-bladder generally empty.^ 

Sec. IV. — Gall-bladder, and its contents. Most of the older 
observers, and some few amongst the moderns, describe the con- 
tents of the gall-bladder, as nearly or quite natural. Thus, Dr. 
Physick and Dr. Cathrall, in their account of " several dissec- 
tions," made in Philadelphia, in 1793, say, that the bile in the 
gall-bladder was quite of its natural color, though very viscid ; 
and Dr. Harrison, in his account of the yellow fever of New Or- 
leans says, that the gall-bladder in most cases contains its usual 
quantity of bile, which is to all appearances healthy, although 
sometimes it is greatly inspissated.^ The weight of evidence is, 
however, quite the other way. Louis says, — *'It is fair to pre- 

' Amer. Journ. Med. Sci., Aug., 1833. 2 ibid., Feb., 1840. 

3 Rapport, &c. Par N. Chervin, p. 12. 

< N. 0. Med. and Surg. Journ., vol. ii. p. 138. 



44ik teejjow 

wmme tm ^cc umiMt of die ansm^ ^aie cf ^e firer, im 
djin^ of t^ jeiknr levo^ of (^brafear, tbat &e seoedoB of Ide 
wasHitalMDiidaiAmAecoiBseof Aa££H9K. Yeijfildeafil 
Noid in tiK: atmiiacli and ssmaA h^e^imtn cf ^ ^bieets 
ve hsKwe opened; anl in &e sane cases, &e gaJl-lifadder 
kas bile than is foiiod in tfe Tictiras of oi&er acole Pl- 
eases; and espedailT kas tban in tihose nbo liare £ed of tjpinnd 
fever, -irrr is abandant, of a pole color, and of Iktk 

coBS£:a;.ce, — :^ ^!ie opposke of ftose fmid in tke eases 

we are now st _ ' ^ wUdk, witii two ^paienl excep- 

tions. Tmdtffadmkgrmmcd^J^'^ Dr. 

Amc . _ — - v: T liaTc erer esandned, with, the 

esBtz _ --5dder, inTaindidleferlook 

fintL T_ body. Tbeaanieistrae 

erf" tiiT - r . "Jiefe may be bile in Ae 

Terr : - r -- ._ ^ : . _ : : -Tsieian is called; bnt m 

- T that bas tenni- 

_ - : - r esciedoiis kas 

c ^ Dr. :?^ott, of 



>I - — T ^ : : - zretLon 

:t : - --7 - iis- 

7 _ \_ T . : ; _ _ .. '^ :ii I be- 

~ -ti tt were 

Dr. 

~ fcver : : ^ : t . :>as, speaks 



. mack 



1 _ junee ; cifiener fie _ i :e to ax drao 

-_ i^—:.: erery case :; :_r :: :. t^ ;i_^:~ fever, 
:k black &dd, resembling tar : : j f is. "-' Dr. De- 

: Vr^i-arFeTsr. p. 14:, -,-__„r. " ! /r-:. Sei. Oct- 1841- 

TcL L p. 79. 



LESIONS —SPLEEN, ETC.— GENERAL REMARKS. 445 

veze found the gall-bladder generally empty, but sometimes con- 
taining a small quantity of bile.^ In a few instances, the gall- 
bladder contains other fluids, or blood. 

Sec. V. — Spleen; mesenteric glands ; urinary organs. No one 
of these organs is the seat of any frequent or important altera- 
tions. Louis and Trousseau found the spleen somewhat softened 
in eight cases; but in half the subjects, it was entirely natural. 

ARTICLE IV. 

MISCELLANEOUS LESIONS. 

Sec. I. — Exterior of the body; muscles. In most subjects, the 
surface of the body is generally yellow. In three of the cases 
examined by Louis and Trousseau, this color was not present ; and 
when the yellowness was not well-marked, it was more so on the 
trunk, and about the head, than on the limbs ; and in some sub- 
jects, it was very slight, over the whole extent of the limbs. Ca- 
daverous muscular rigidity is generally strongly marked; and the 
muscles preserve their healthy firmness, color, and cohesion. 

ARTICLE V. 

GENERAL REMARKS. 

Sec. I. — Relation between Symptoms and Lesions. It is quite 
clear, I think, that the febrile symptoms, — the chills, the heat of 
the surface, the accelerated pulse, and so on, — cannot with any 
propriety be attributed to local inflammations, in any part of the 
body. In the first place, these inflammations, so far as we can 
ascertain from the lesions found after death, are sometimes absent; 
and, in the second place, we have good reasons for believing that 
the inflammations usually occur after the subsidence, or at least, 
after the partial subsidence of the febrile symptoms. Louis says, 
the commencing coldness of the lower extremities usually coin- 
cides with the appearance of the black vomit, and probably de- 
pends upon this gastric hemorrhage. 

There is no evidence of any special connection between the 

^ Traite de la Fievre Jaune. Par Jean Deveze, p. 66. 



446 YELLOW FEVER. 

state of the tongue aad that of the stomach. There can be no 
reasonable doubt, perhaps, that the vomiting in the latter stage, 
and near the close of the disease, is more or less dependent upon 
the lesions of the gastric mncous membrane, which have been 
described; bnt ve shall be canying onr interpretation further than 
our facts will justify ns in doing, if we attribute the vomiting, and 
the other gastric and epigastric symptoms, always and invariably, 
to the inflammation of this membrane. The grounds of this qua- 
lification are found in the fact, already stated, that in a certain 
proportion c^ cases, attended Kke the rest by vomiting, the mu- 
cous membrane of the stomach presents no traces of previous in- 
flammation. If it is alleged here, as it has been, that inflamma- 
tion had existed, but that its results had disappeared with death : 
our reply is, that the allegation is wholly gratuitous ; and that we 
have no right, in the absence of positive facts, to indulge in asser- 
tions, which are necessarily more or less conjectural. In relation 
to the particular question before us, it is, at least in the actual 
ccHidition of our knowledge, more philosophical to refer the vomit- 
ing, as we have referred the production of the matter itself of 
black vomit, partly at least, to some anterior and more specific 
morbid condition, the precise nature of which is yet wholly un- 
known. Similar remarks may be made in regard to the loss 
of appetite, the thirst, the epigastric distress, and the general 
restlessness, so common towards the close of fatal cases. None 
of the symptoms can be referred, with entire constancy or uni- 
fonnity, to the appreciable lesions of the organs making up the 
pathological anatomy of the disease. 

According to Louis, the colicky pains of the abdomen, which 
are present in a certain number of cases, often coincide, in their 
appearance, with the discharges of black matter from the bowels: 
80 that they are probably occasioned by the presence of this 
matter. 

The yellow color and anemic condition of the liver do not reveal 
themselves by any characteristic symptoms during life. It is 
reasonable, however, to attribute the absence of bile from the 
gasbo-intesfinal discharges to the morbid condition of the liver. 

I am not aware that the suppression of urine, which is occa- 
sionally met with, has been found connected with any apprecia- 
ble alteratifm ci the kidneys. 

The headache which so constantly attends the early period of 



LESIONS.— CAUSES OF DEATH. 447 

yellow fev^er, as well as the other local pains, must be regarded 
as a purely nervous phenomenon, in no way dependent upon any 
appreciable alteration of the cerebral, or the cerebro-spinal, ap- 
paratus; and the same thing is true of the delirium and coma 
which are occasionally present towards the close of the disease. 
These latter symptoms are as common in cases where the brain 
is free from any alteration, as they are in cases where the lesions 
are found. For similar reasons, none of these symptoms can be 
referred directly to the inflammation of the stomach, or to any 
other of the local lesions. 

It is very natural that we should refer the yellowness of the 
skin to the morbid condition of the liver ; and perhaps this ex- 
planation of the phenomenon is more rational than any other. It 
is quite clear, that in most cases, and it may be in all, there is, 
early in the disease, a suspension of the functions of the liver, 
and it is a very reasonable conclusion, that the two phenomena 
are connected. It is well to remember, however, that the yellow- 
ness of the surface is frequently preceded by a more or less in- 
tense sanguineous congestion of the skin, and that the discolora- 
tion may depend upon some modification in the condition of the 
blood, or the action of the cutaneous capillaries, or both, quite in- 
dependent of the state of the liver. The tendency to hemorrhage 
depends also, probably, upon the altered state of the blood. 

The hemorrhagic spots and masses in the tissue of the lungs 
do not indicate their presence by any symptom during life, — a 
fact that furnishes us with another lesson, if any such w^ere needed, 
of the danger of trusting, in any degree, to what we call analo- 
gies, or a pnori probabilities, however reasonable and plausible 
these may seem to be. 

There is no proof, that the character of the pulse is dependent 
upon any appreciable morbid alteration of the heart. 

Sec. II. — Causes of Death. The present seems to me as ap- 
propriate a place as any for a few remarks upon the causes of 
death. Keeping myself, as I have always endeavored to do in 
these interpretations, strictly within the authority of well ascer- 
tained phenomena, what I have to say must necessarily be rather 
approximative, and conjectural, than positive in its character. 
Considering the rapidity with which the changes in the liver and 
in the mucous membrane of the stomach take place, it is not un- 



448 YELLOW FEVER. 

reasonable to suppose, that in a certain number of cases, these 
changes, together with the hemorrhagic effusion, play a very im- 
portant part in the destruction of the patient's life; they may per- 
haps, of themselves, be considered as adequate causes of this 
result. The relative agency and importance of each of these 
phenomena it would be an idle labor to attempt to ascertain. 
There are many cases, however, especially such as are attended 
with but slight lesions, or with no appreciable lesions, of the 
stomach, in which it seems to me more philosophical to look else- 
where for the causes of death; and in which, if our knowledge 
was sufficiently accurate and extensive, they would probably be 
found in the altered state of the blood, and in other immediate 
and remote effects of the unknown etiological poison of yellow 
fever upon the different tissues of the body. The analogies of 
many other diseases, especially such as are of a malignant, or 
congestive, character, like Asiatic cholera, scarlatina, typhus 
fever, and so on, are all in favor of this interpretation. 



449 



CHAPTER IV, 

CAUSES. 

In the multitudinous records of the history and literature of 
yellow-fever, there is no portion so involved in interminable con- 
fusion and embroilment, as that which relates to its causes. After 
as thorough and careful an examination as time and opportunity 
have enabled me to make, I shall now do what I can in endeav- 
oring to render this subject as intelligible as its nature and pre- 
sent condition will admit, following the same general plan by 
which I have been guided in the preceding portions of my book. 

Sec. I. — Locality. Amongst the most striking circumstances 
in connection with the etiology of yellow fever, are those of the 
geographical boundaries within which it is confined, and the more 
circumscribed localities in which it prevails. In the first place, 
the disease is very rarely met with south of the twentieth degree 
of south, or north of the fortieth degree of north latitude. The 
range of latitude, in w^hich it prevails most extensively, lies be- 
tween thirty-six or thirty-seven, and forty-one or forty-two de- 
grees north, in Europe ; and between ten and thirty-five degrees 
north, in America. In the second place, even within these limits, 
yellow-fever is much more frequent in the western than it is in 
the eastern hemisphere, and still further, it is much more common 
in certain portions of Europe and America than it is in Africa. 
In the third place, yellow-fever is almost always confined to com- 
mercial seaports ; although it is occasionally met with in the towns 
and cities in the neighborhood of the latter, situated in the inte- 
rior of the country, or on the banks of navigable rivers. In the 
fourth place, yellows-fever is very fequently strictly circumscribed, 
within certain limited and w^ell-defined portions of the locality, 
or the city, in which it prevails. These four facts in connection 
with this element of the etiology of the disease are well ascer- 
29 



450 YELLOW FEVER. 

tained ; there is no doubt, that I am aware of, or difference of 
opinion in regard to them. 

The places in Europe which have been most frequently and 
most extensively visited by this disease, are the seaports of the 
north coast of the Mediterranean, especially those of Spain. Dr. 
Gillkrest enumerates eighty-five towns or cities in the maritime pro- 
vinces of Andalusia, Murcia, Valencia, and Catalonia, where yel- 
low-fever has been known to prevail. The most important of these 
are Cadiz, Gibraltar, Malaga, Carthagena, Alicante, and Barcelona, 
all situated on the sea coast. Dr. Gillkrest says, further, that the 
disease is occasionally met with, to a limited extent, in some of 
the towns and cities at a considerable distance from the sea ; 
amongst these, he mentions Cordova, situated on the Guadalqui- 
ver, seventy miles in a direct line from the coast ; and Ronda, 
sixty miles north of Gibraltar. Similar facts are of frequent oc- 
currence in the United States. The interior towns which are 
oftenest visited by yellow-fever, are those situated above New 
Orleans, on the Mississippi River, especially Natchez and Vicks- 
burg. In 1844, Woodville, a small inland town of Mississippi, 
fifteen miles in a direct line from the river, suffered severely from 
the disease; as did also many isolated plantations in the surround- 
ing country} 

The principal seats of the disease, in America, are the towns 
and cities lying along the shores of the Atlantic ocean, from 
Charleston, south ; along those of the entire Gulf of Mexico, and 
of most of the West India Islands. The shores of this western 
Archipelago and Gulf, constitute the great and prolific hot-bed in 
which is constantly generated the unknown poison of the dis- 
ease ; they have been the crowded Necropolis of the successive 
swarms of adventurers and invaders, who have annually flocked 
thither from Europe and America, ever since their discovery. 
Chisholm says, in his dedication, that more than twelve thousand 
of his countrymen have perished within these islands in the short 
space of two years! 

In connection with the localities, or the habitat, of yellow fever, 
it is important to notice, that it. frequently occurs, and prevails 
extensively, on ship-board. This has been so often witnessed, as 
to render it quite certain, that in yellow fever seasons, and places, 

* N. 0. Med. Journ., vol. i. p. 530. 



CAUSES.— LOCALITY. 451 

the hold of a ship often constitutes a very prolific nidus for the 
generation of the poison of the disease. Dr. Gillkrest enumerates 
nearly forty vessels, or squadrons, in which, at different periods, 
the disease has appeared.-^ The first appearance of yellow fever 
on ship-board usually takes place while vessels are in port, or very 
soon after they have left port. Dr. Burnett, who saw a great deal 
of the disease in the ships of the British fleet on the Mediterranean 
station, says, that with one exception, he never knew an instance 
where the crew^ of a vessel were attacked after being some time at 
sea.^ Dr. Currie, of Philadelphia, supposed that crowded trans- 
ports, or ships of war, generally, if not always, constituted the 
original and proper sources of the matter of contagion, or the poi- 
son of the disease.^ Dr. Barrington says, that the disease made 
its appearance on board the United States' ship Hornet, in 1828, 
while lying at Sacrificios, a small island about three miles from 
Vera Cruz. The ship had been lying there at anchor twenty-six 
days, when the first decided case occurred ; there was no epide- 
mic in the city of Vera Cruz, excepting the dengue ; nor was the 
fever prevalent at any place where the vessel had touched during 
her cruise. ' There can hardly be a doubt as to the origin of the 
disease, here, in the ship. Other cases of a like character are on 
record. In 1799, the frigate General Green sailed from Newport, 
Rhode Island, for Havana. She had tempestuous weather^ 
leaked badly, and became very foul, the weather being excessive- 
ly hot. Yellow fever appeared amongst her crew, before she ar- 
rived in port, which was at the time free from the disease.'' M. 
Chervin has collected a considerable number of similar instances, 
which seem to be w^ell authenticated, and which, so far as I know,, 
are uncontradicted.^ 

There is another circumstance in connection w^ith the preva- 
lence of yellow fever on ship-board, which ought to be stated. 
The disease is said in many instances to be confined to certain 
portions of the ship ; or at least to prevail more extensively in cer- 
tain portions than in others. Dr. Wilson says, — " It is always at 
the beginning confined to a small space. It often continues for 
a while in one berth, whence it sometimes crosses to the opposite 
berth; sometimes it travels along one side, returning pretty regu- 

> Cyc. Prac. Med., vol. ii. p. 270. 2 Burnett on the Med. Fever, p. 3. 

3 Currie's Dis. of Am., p. 60. 

4 Deveze,p. 158. 6 Rapport de I'Acad. Roy. de Med., 1827, p. &. 



452 YELLOW FEVER. 

larly by the other ; and sometimes it traverses the ship from the rear 
to the forepart, or in a contrary direction. But in a majority of 
instances, it begins in the vicinity of the pumps and main hatch- 
way, where the shell of the ship is most dependent, where water 
draining from other parts collects, and where heat is most in- 
tense."^ 

The fact of the limitation of yellow fever to certain well defined 
quarters, or neighborhoods, of the cities in w^hich it is epidemic, 
has been so generally observed, that it is hardly necessary to mul- 
tiply examples of this limitation. The extension of the boundaries 
of this infected district, as it is called, almost always takes place 
gradually. Dr. Nott, of Mobile, in a private letter to me, says, — 
'* I have, on two occasions, seen yellow fever commence in a point 
in the town, and eat through it, square by square, like worms in 
a cotton field, — taking each time nearly a month for this process." 
Arejula, in his account of the epidemic of Cadiz, in 1800, says, — 
" We also ascertained that the disorder not only spread from one 
individual to another, but that it passed from one house to the next 
adjoining, and so on along the street, ultimately affecting the 
whole district.^ Arejula also gives an account of the origin and 
spreading of the disease at Malaga, in 1803. He traced it regu- 
larly and gradually from its focus, first to one house, then to ano- 
ther, adjoining, and so on, through a whole street or district.^ M. 
Berthe, who was one of the French commission to investigate the 
epidemic of Andalusia, in 1800, says, — " It was distinctly ob- 
served, that the malady affected to seize, with scarcely any inter- 
ruption, all the houses which were situated on the same side of a 
street, and that it rarely passed over to the other side, where the 
streets were wide and w^ell aired. In some parts of the town the 
distemper has been seen to stop, as it were, for a time, as soon as 
it had reached to houses standing in a public square, and even to 
retrograde with respect to the direction in which it had previously 
advanced, by appearing in the adjoining houses, rather than in 
those which were separated by the breadth of the square."'' The 
Cadiz epidemic of 1800 commenced in a quarter of the city called 
the Barrio de Santa Maria, to which quarter it was at first con- 
fined ; it gradually spread to other portions of the city. The same 

* Memoirs of West Indian Fever, p. 157. 

2 Reports, etc., by Sir J. Fellowes; p. 36. 3 ibid., p. 164. 

4 Bancroft's Essay, p. 459. 



CAUSES.— SEASON. 453 

thing is true of other epidemics. Dr. Hosack says, — " Whenever 
the yellow fever has been introduced into the cities of the United 
States, its first extension has always been slow and gradual. 
Upon several occasions its boundaries have been accurately de- 
fined by our board of health. This was remarkably the case in 
New York, in 1805. The disease, in that year, was confined, for 
some wrecks, to a small portion of the eastern side of the city, and 
as stated by the board of health, not a case occurred in any part 
of the town, that was not referable to that as its source. In a 
short time, the infection extended a few streets further ; the board 
of health again defined its limits, and again declared, that still 
not a case had occurred that could not be traced to this part of 
the city as its source."^ The disease, at Gibraltar, is almost al- 
ways confined to the western face of the rock, and to a small vil- 
lage situated at the base of the rock, on its eastern side. 

Sec. II. — Season. The period of the year, during which yel- 
low fever prevails most extensively, varies with the climate and 
temperature of different localities. In the cities of the United 
States, it usually commences in the months of July or August, 
and continues till the first frost. The great epidemic of 1793, in 
Philadelphia, began early in August, and ceased about the middle 
of October; the largest daily mortality taking place during the 
second w^eek of the latter month. At Seville, in 1800, the epi- 
demic commenced on the 23d of August, and continued till 
December; the principal mortality was in October.^ 

The editors of the New Orleans Medical Journal have published 
a tabular statement of the cases of yellow fever received into the 
Charity Hospital of that city, for twenty-one successive years, 
from 1822, to 1843, inclusive, with the dates of the first and last 
case, for each year. During fifteen of these twenty-one years, the 
disease w^as sufficiently extensive to be called epidemic; the num- 
ber of cases received ranging from ninety-four to eleven hundred 
and thirteen. The dates of the first receptions vary from May 
23d, to September 3d; the largest number falling in the months 
of July, and August. The dates of the last receptions vary from 
November 13th, to December 31st; the largest number falling in 

* Hosack's Med. Essays, vol. i. p. 309. 
2 Reports, etc., by Sir J. Fellowes, p. 421. 



454 YELLOW FEVER. 

the month of November, and almost always after its middle period.^ 
Sir James Fellowes has published a similar abstract in connection 
■with the general Spanish epidemic of 1804. He gives the popu- 
lation of twenty-three towns, in which the fever prevailed ; the 
period of its commencement and cessation in each; the day of 
the largest mortality; the total number of deaths; and the pro- 
portion of males and females. The earliest period of the com- 
mencement of the disease was June 29th, at Malaga; the latest 
period was October 5th, at Villamartin, a small town in the pro- 
vince of Seville ; the disease began in ten towns, in August ; in 
nine, in September ; and in three, in October. The earliest pe- 
riod of the cessation of the disease was October 28th, at Grenada ; 
the latest period was January 23d, at Carthagena. The disease 
ceased in the course of October, in one town ; in November, in 
seven; in December, in twelve; and in January, in two.^ Mr. 
Doughty says, that in Jamaica, the disease generally prevails from 
the beginning of August to the end of December or January. 

Sec. III. — Temperature, and Weather. That yellow fever is a 
disease of warm climates, and that it prevails most extensively 
during the warmest seasons of the year, no one pretends to deny 
or to doubt. But some observers have gone further than this, and 
have alleged that the disease is much more likely to occur, in the 
localities that are subject to it, in very warm, and wet seasons, 
than in those that are somewhat cooler and drier. They assert, 
that there is a general connection between certain appreciable 
states of the weather, and the disease. Dr. Hosack says, yellow 
fever prevails most extensively when the air is unusually moist 
and the weather hot.^ Dr. Doughty says, it is more likely to 
occur in the West Indies, after copious rains. Sir Gilbert Blane 
said that the fever was restricted to those regions where the range 
of the temperature was as high as 80°. Others have alleged, that 
the disease can occur only in those places where the average tem- 
perature at 3 o'clock P. M. is not less than 79°, during the sum- 
mer, and especially during the two whole months of June and 
July; and that its extent and severity will he in proportion to the 
degree in which it exceeds this point. There is no doubt, what- 

' N. 0. Med. Jour., vol. i. p. 103. 

2 Reports, etc., by Sir J. Fellowes, p. 478. 

3 Hosack's Med. Essays, vol. i. p. 305. 



CAUSES.— TEMPERATURE.— WEATHER. 455 

ever, that the disease is generally found where these high tem- 
peratures prevail; but it is far from being settled that the disease 
is directly and immediately dependent upon these degrees of heat ; 
yellow fever has sometimes occurred at Stoney Hill, in Jamaica, 
thirteen hundred feet above the level of the sea, wdth a mean an- 
nual temperature of only 70°. 

Sir James Fellowes gives tables of the temperature, furnished 
by Arejula, at Cadiz, from 1789, to 1803; from which it is quite 
clear, that the hottest years loere not the sickliest. They show no 
apparent connection between the temperature, and the disease.^ 
Hillary, who studied this subject with great care, says, — "It does 
not appear, from the most accurate observations of the variations 
of the weather, or any difference of the seasons, which I have 
been able to make for several years past, that this fever is any 
way caused, or much influenced, by them : for I have seen it at 
all times, and in all seasons of the year, in the coolest as w^ell as 
in the hottest time of the year; except that I have always ob- 
served, that the symptoms are generally more acute, and the 
fever usually higher, in a very hot season, especially if it was 
preceded by warm, moist, weather, than it usually is when it is 
more cool."^ M. Catel believes that the epidemic prevalence of 
yellow^ fever at Martinique and at other places is greatly favored 
by the w^arm and humid w^inds from the southeast; and by a stag- 
nant atmosphere.^ He says, further, that at Martinique the dis- 
ease is always rendered more severe and malignant, by violent 
thunder storms. Dr. Gillkrest, in his account of the Gibraltar 
epidemic of 1828, says, — -"By ample tables in our possession, it 
does not appear that either before the appearance of the disease 
in the garrison, or during its progress, any atmospheric changes 
took place, differing materially from other years in which epi- 
demics did not occur. The average heat was not greater than 
that of the preceding year. The quantity of rain, which had 
fallen up to the appearance of the epidemic, was within a fraction 
of that which fell in 1827. The influence of a prevalent easterly 
wind had been much dwelt upon in the explanations offered re- 
specting the epidemic of 1804; but, in 1828, no unusual preva- 
lence of that wind took place. "^ According to Humboldt, there 

* Reports, etc., by Sir J. Fellowes, p. 413 et seq. 

2 Rush's Hillary, p. 107. 3 De la Fievre Jaune, &c., par M. Catel. 

4 Cyc. Pract. Med., vol. ii. p. 279. 



456 YELLOW FEVER. 

was no yellow fever at Vera Cruz for eight years previous to 1794, 
although there was nothing unusual in the state of the weather 
during this period.^ The editors of the New Orleans Medical 
Journal, in their notice of the health of the city, for 1844, make 
the following remarks: — "The health of New Orleans was per- 
haps never known to be better. No epidemic whatever has pre- 
vailed during the year. The summer has been one of the hottest 
ever experienced ; with frequent showers, during July and August. 
Thus it would appear we have had a large share of two of what 
have generally been considered the most essential agents in the 
production of the remote cause of summer and autumnal diseases, 
— to wit, — heat and moisture. As to the other ingredients, dead 
animal and vegetable matter, one would suppose there was never 
any deficiency, about such a place as New Orleans. Well, we 
have here all the hypothetical elements of hypothetical malaria; — 
but where are the much dreaded consequences?"^ The Board of 
Health of the city of New Orleans, in a report made in 1846, 
say, — " The experience of former years would lead us to conclude, 
that more or less rain, or a greater or less degree of heat, has very 
little to do with the production of yellow fever ; for that disease 
has been known to prevail here alike in dry and wet seasons, and 
without regard to the variations of temperature in the summer 
months."^ 

Sec. IV. — -Age. Writers upon yellow fever very rarely say 
anything about the age of its subjects. The reasons are suffi- 
ciently obvious why a very large proportion of its victims should 
be those in the middle and most active period of life. It occurs, 
however, not unfrequently amongst children. 

Sec. V. — Sex. It is quite certain that yellow fever destroys 
very many more males than females; but, in order to determine 
positively, the real difference in the susceptibility of the sexes to 
the disease, more accurate and conclusive investigations are ne- 
cessary, than have yet been made. The great and uniform pre- 
ponderance of male over female deaths is in no degree sufficient 
to settle this question; since it is obvious, at first sight, that under 
the circumstances which generally attend the epidemic prevalence 

1 Cyc. Pract. Med., vol. ii. p. 291. 2 N. Q. Med, Jour., vol. i. p. 216. 

3 Ibid., vol. ii. p. 475. 



CAUSES.— SEX. 457 

of yellow fever, the number of males who are exposed to the essen- 
tial cause of the disease, and who are at the same time susceptible 
of the disease, is almost always vastly greater, than that of females. 
The mortality from yellow fever is almost wholly confined to 
strangers, and the iinacclimated in cities where it prevails, and a 
vast proportion of these are men. I do not mean by these remarks 
to deny, that females are less liable to the disease than males; I 
mean merely to say, that the apparent results of the tables of mor- 
tality do not justify the conclusions which have been drawn from 
them, for the obvious reasons that I have just given. In this con- 
nection, it would be interesting and important to ascertain whe- 
ther there is any difference, depending upon sex, in the liability 
of the children of residents in yellow fever cities to the disease. 
After these qualifying remarks, the reasonableness and necessity 
of which can hardly be called in question, I proceed to state some 
of the results of observation, in regard to the actual difference in 
the prevalence of the disease in the two sexes. In a short but 
interesting paper on the History, Topography, and Causes of Yel- 
low Fever, by Dr. Bennet Dowler, published in volume second of 
the New Orleans Medical Journal, notice is taken of a terrible 
epidemic which ravaged the island of Barbadoes in 1647. In a 
history of the epidemic, published by Ligon, ten years after its 
occurrence, it is stated, that '■'•for one woman that died, there were 
teri men.''"' Dr. Gillkrest says, — "In some epidemics, females 
have remained wonderfully exempt: this was the case during a 
terrific epidemic at Dominique, and Martinique, in 1801, as the 
writer of this witnessed ; for while two battalions of the 68th regi- 
ment, composed of fine young men, suffered so much from the 
disease as not to be able latterly to furnish any men for duty, and 
had lost forty-six oflficers, within six months, not a single w^oman 
was attacked; and it may be observed that, in those days, more 
females w^ere allowed to embark with regiments from home than 
at present."^ 

During the Spanish epidemic of 1804, the aggregate mortality 
in twenty-three towns was 45,822; the male deaths amounting to 
28,352; the females, to 17,470. This general result, on so large 
a scale, would seem quite conclusive as to the greater liability of 
the male than the female sex to this disease; but a closer exami- 

' Cvc. Prac. Med., vol. ii. p. 279. 



458 YELLOW FEVER. 

nation and analysis of the table will strengthen the doubts that I 
have already ventured to express, in relation to this subject. 
Taking five of the large sea ports, the difference in the mortality 
of the sexes is very great, as might naturally be supposed. The 
male deaths in Malaga, Alicante, Cadiz, Carthagena, and Velez 
Malaga amount to 21,805; and the female deaths to only 11,713. 
But in five of the larger inland towns, more or less removed from 
the coast, where, we have a right to presume, there are fewer 
strangers, and sailors, the female mortality even exceeds the male 
mortality; — the former amounting to 3,961, and the latter to 
3,576. In Ecija, an interior town of Seville, some eighty miles 
from the sea, the male mortality was 1,380; and the female mor- 
tality 2,422.^ The aggregate mortality in Charleston, S. C, 
during ten years, between 1817, and 1839, was as follows; — 
males, nine hundred and seventy-six; females, one hundred and 
seventy-eight. 

Sec. VL — Race. The African race is less liable to yellow 
fever than the Caucasian. This comparative exemption of ne- 
groes from the disease has long been noticed. During the Phila- 
delphia epidemic of 1793, Dr. Rush published in one of the daily 
newspapers the following extract from Dr. Lining's History of the 
Yellow Fever, as it had four times appeared in Charleston, South 
Carolina. "There is something very singular in the constitution 
of the negroes, which renders them not liable to this fever; for 
though many of them were as much exposed as the nurses to the 
infection, yet I never knew of one instance of this fever amongst 
them, though they are equally subject with the white people to 
the bilious fever." In consequence of this publication, the Afri- 
can Society voluntarily offered to furnish nurses and attendants 
for the sick. "It was not long," continues Dr. Rush, — "after 
these worthy Africans undertook the execution of their humane 
offer of services to the sick, before I was convinced I had been 
mistaken. They took the disease in common with the white peo- 
ple, and many of them died with it. A large number of them 
were my patients. The disease was lighter in them than in white 
people. I met with no case of hemorrhage in a black patient."^ 
Dr. Lewis, in his account of the Mobile epidemic of 1843, says, — 

^ Reports, etc., by Sir J. Fellovves, p. 478. 
2 Rush's Med. Inq., vol. iii. p. 80. 



CAUSES.— CONSTITUTION. 459 

"Negroes were frequent subjects of fever; these cases were simi- 
lar to the mild grade of the yellow fever of the season, yet never, 
as far as my observation extended, arriving at the stage of black 
vomit; nor did a single case prove fatal in my practice amongst 
this class of persons. Some four or five mulattoes died of black 
vomit, during the season. Many cases terminated in the charac- 
teristic hemorrhages, and others again passed through all the 
stages of grave yellow fever, requiring the same active stimula- 
tion to sustain them in the collapse stage, that were used under 
similar circumstances with the whites. These cases were con- 
fined to the mulattoes. Notwithstanding the great fatality that 
attended this class in 1813, we are bound to conclude that, as a 
general rule, they are exempt from the noxious influence of the 
poison of yellow fever. They constitute, especially in autumn, a 
large portion of our population ; many of them recently from Vir- 
ginia, and the Carolinas, coming strictly under the head of unac- 
climated persons. Those unacclimated suffer more than those 
long resident amongst us; still they have black vomit so seldom 
as scarcely to constitute an exception to the general rule."^ In 
1820, says Dr. Daniell, near three hundred native Africans, 
recently captured on the coast, by government vessels, were 
brought into Savannah. They remained there during an epidemic 
yellow fever, but not one suffered from the disease.^ Dr. Dick- 
son says he has never known an African negro to be attacked by 
yellow fever.^ 

Sec. ^1\.— Constitution. It would seem that yellow fever is 
more likely to attack the stout and plethoric than the more feeble 
and delicate. Mosely says the disease is incidental only to the 
gross, inflammatory and plethoric; and again, — "subjects most 
likely to be attacked by the Endemial Causus, are the florid, the 
gross, the plethoric, — that sort of strong, full, youthful people, 
with tense fibres, who in England are said to resemble the pic- 
ture of health." Sir Gilbert Blane says, — " Those who are young, 
fat, and plethoric, are most apt to be attacked ; and more of our 
officers in proportion were seized with it than the common men."^ 
It should be remembered that a pretty large proportion of the un- 

• N. O. Med. Journ., vol. i. p. 416. 2 Fevers of Savannah, p. 64. 

3 Dickson's Essays, &c., vol. i. p. 345. 4 Qbs. Dis. Seamen, p. 398. 



460 YELLOW FEVER- 

acciimated are likelj to consist of tiiis class of persons, — the 
yonnsr? actiTe, and robust, coming from cooler climates. 

Sec. Vlil. — Ocagw^Kwi. The largest number of persons de- 
stroyed by yellow feTer are soldiers and sailors, the reasons for 
which are sofficiently obirions. It is alleged, by many writers, 
that there are certain occupations which render persons engaged 
in them to a great extent exempt from the disease. This has been 
said to be the case with butchers, and workers in leather, soap, 
and tallow- I do not think there is any good reason for this 
opinion : — ^the eiridence, so far as I can judge, upon which it is 
founded, being altc^ther inadequate. Dr. GiUkrest says, — "Cir- 
cumstances connected with localities being equal, the upper 
classes of society seem on all occasions, to suffer from attacks, in 
a full proportion." 

Matthew Carey, in his account of the Philadelphia epidemic of 
1793, says, — "To the JiUes de joie, it has been very fatal. The 
wretched debilitated state of their constitutions rendered them an 
easy prey to this dreadful disorder, which very soon terminated 
their miserable career. To hired serrant maids, it has been yery 
destructive. Numbers of them fled away ; of those who remained, 
Teiy many fell, who had behayed with an extraordinary degree of 
fidelity."* In this connection it may be added, that all the attend- 
ants upon the Greneral Hospital of Barcelona, during the epidemic 
of 1821, who died with yellow feyer, are Scdd to haye been suf- 
fering at tbe time under chronic diseases. Dr. O'Halloran says, 
the phy^cians of Barcelona generally remark, that scarcely an 
indiyidual escapes an attack of yellow fever, who labors under 
venereal or chronic disease.^ 

Sec. IX. — Acciimation. In this chapter, more appropriately 
than anywhere else, may be placed a few remarks upon the influence 
of a prolonged residence in yellow fever localities, in renderings the 
system unsusceptible to the poison of the disease. This change 
in the system is called acclimaiion. It is most speed dy and 
eflectually wrought, by the occurrence of the disease itself; but it is 
quite evident, that it may be more slowly and gradually effected, 
by a caidmued residence in yellow fever r^ons. The precise 

' Carey's Sbot Aceaanf, eta, p. 61. « O^Halioxan on TeHow Fever, p. 9S. 



CAUSES.— ACCLIMATION. 461 

conditions and causes of this exemption have not been very posi- 
tively ascertained; and it is probable that they vary somewhat in 
different cases. There is a great difference, in different seasons 
and places, in the degree of protection afforded by this modifica- 
tion of the system. During mild epidemics, the protection is 
quite perfect ; but when the character of the disease is highly 
malignant, the protection, in many instances, wholly fails. Some 
observations, relating to this subject, by Dr. Lewis, will be found 
in the chapter on bibliography. He says, further, that "of one 
hundred and twenty cases that terminated fatally, at Mobile, in 
1843, seven w^re natives; three were from Charleston; five from 
New Orleans; twenty had resided in Mobile, from five to ten 
years, annually avoiding the sickly months ; fifteen had been con- 
stantly in the city, from four to seven years, — amongst whom 
Avere four who had the fever in 1839. Sixty were strangers, never 
having passed a summer in a yellow fever locality. These facts 
tend to the following conclusions. In healthy years, what is called 
sporadic yellow fever is confined to strangers. In years w^hen the 
disease does not prevail so generally as to amount to an epidemic, 
the grave cases are confined to the unacclimated. In epidemics, 
the natives, old residents, and even those who have had the disease 
in previous years, are frequently mildly attacked ; but the strangers 
are very generally seized, and have, in fact, to bear the violence 
and malignity which belong to the fever."^ 

It would seem that this protective power of acclimation does 
not extend to localities which are usually exempt from the dis- 
ease. A very remarkable circumstance, in support of this remark, 
occurred at Woodville, in Mississippi, in 1844. This inland 
town then contained about eight hundred inhabitants, mostly 
natives, or old and permanent residents. At least it is stated that 
the town had been of gradual growth, for forty years, and that 
there had been no sudden immigration. After the appearance of 
yellow fever in the tow^n, nearly tw^o hundred persons fled to the 
surrounding country; hut nearly all who remained were attacked 
by the disease. Dr. Stone, in his report, says, — " Few persons 
escaped; I know of not more than five adults, and no children, 
except those persons, about tw^enty in number, who had had yel- 
low fever formerly. Of these, one had it in Charleston, forty 

» N. 0. Med. Jour., vol. i. p. 418. 



462 YELLOW FEVER. 

years ao-o; others in New Orleans, Bayou Sara, Natchez, the 
West Indies, and elsewhere ; and all escaped, with perhaps, one 
exception— a mild case."^ 

The great endemic of the western coast of Africa is periodical 
fever ; but yellow fever has occasionally appeared at some of the 
settlements. It prevailed at Sierra Leone, in 1823, and in 1829, 
and was as fatal amongst the old residents as the new comers.^ 

It, would seem that at certain times and in certain localities, 
the poison of yellow fever acquires such an intensity as to over- 
bear all the influences which ordinarily resist' it. Everything 
gives way before it; neither age, sex, nor race is spared; and 
not even the most thorough acclimation, nor the previous occur- 
rence of the disease is sufficient to ward off its assaults. 

This preservative influence of acclimation seems to be pretty 
readily lost or destroyed, or at least greatly diminished, by a re- 
moval from yellow fever regions to cooler latitudes. Bally 
reports the case of a lady, who, born in Canada, had resided for 
thirty years in one of the Antilles. After an absence of two 
years, passed in the north, she returned, and soon after died with 
yellow fever, at the age of fifty-four years.^ 

Sec. X. — Exemption from Subsequent Attacks. Yellow fever 
very rarely occurs a second time in the same individual. This 
exemption from a second attack of the disease was noticed during 
the last century; and it has been since corroborated by the obser- 
vations of many French, English, Spanish, and American phy- 
sicians, amongst the earliest and most distinguished of whom 
were Professor Arejula, and Sir William Pym. This point in 
the natural history of yellow fever was made the subject of a 
special and formal investigation, after the cessation of the epi- 
demic at Gibraltar, in 1828. At the instance of Sir William 
Pym, a commission was appointed, for the express purpose of 
collecting such facts as might settle the question. The commis- 
sion consisted of thirteen physicians, — French, English, and 
Spanish. Louis was appointed President, Dr. Barry, Vice-Pre- 
sident, and Trousseau, Secretary. The distinguished Chervin 
was also a member of the commission. The medical men of 
Gibraltar, civil and military, thirty-three in number, all of whom 

* N. 0. Med. Jour., vol. i. p. 532. 2 Boyle's Dis. West. Africa, p. 289. 

3 Deveze, p. 107. 



CAUSES.— SECOND ATTACK. 463 

had been familiar \vith the disease, appeared before the commis- 
sion, and stated the results of their experience. The aggregate 
number of patients ^\'ith the disease, seen or treated by them all, 
amounted to about tioenty-seven thousand. These physicians 
were invited to state the number of cases, in which they had 
known the disease to occur a second time; and as simple asser- 
tions were inadmissible, the commission decided that they would 
receive those cases only, in which the symptoms of the first and 
second attacks could be given, whether these symptoms had been 
noted by the physicians who communicated them, or whether they 
came through the patient himself, but w^ere unequivocal. The 
whole number of cases of presumed double attack, thus commu- 
nicated to the commission, was only thirteen ! Upon these thir- 
teen cases, each member of the commission expressed his opinion 
by a vote, writing upon a piece of paper the word evident, pro- 
bable, doubtful, or inadmissible, for each case. A majority of the 
commission declared, in this manner, one of the cases, evident; 
three of them, probable; and the remainder, doubtful, or inad- 
missible. The following fact, on a much smaller scale, but 
hardly less conclusive, was communicated to the commission by 
M. Broadfoot. The military domestics employed during the epi- 
demic in the care of the sick were one hundred and sixty, in 
number, and none of them had had yellow fever in any anterior 
epidemic. The civil domestics were sixty-one in number, and, 
with two exceptions, had already had the disease. These two, 
and these two only, amongst the last, had the disease ; and forty 
of the military domestics, all the rest escaping. Other facts of a 
similar character were also presented to the commission. Slight 
and mild attacks of the disease seemed to be quite as preservative 
against its recurrence, as grave and severe ones; and it did not 
appear, that the protective effects were in any degree diminished 
by time. 

Dr. Lewis has investigated this question wath some care, and 
the result of his inquiries differs somewhat from that which I have 
just given. Five respectable citizens of Mobile, he says, have 
had the disease as many as three times, according to the testimo- 
ny of competent judges. As many as twenty of his own patients, 
who were mildly attacked in 1843, stated, that according to their 
physicians, they had already had yellow-fever, during the epide- 
mics of 1837, or 1839. Dr. Lewis concludes, that in 1843, 



464 YELLOW FETER. 

about one-fiiili of the patients who had mild yellow ferer, had 
been subjects of the disease during preTious epidemics. His 
opinion seems to be, that at least during the preTalence of grare 
epidemics, persons who hare previously had the disease are. to a 
certain extent, liable to second attacks in a mild form.^ 

Sec. XI. — Epidemic Influences. Yellow ferer usually prevails 
in a given locality, more or less extensively ; it becomes, for the 
time being, as it is said, epidemic. The returns, or recurrences 
of these epidemic seasons, are altogether uncertain and irregular : 
— ^they give no note of their coming; the laws which govern the 
revolutions of their periods are wholly unknown to us. One of 
the most remarkable and extensive of these large epidemic: periods, 
was that which commenced in the year 1793, and continued for 
several years. I do not propose to go into any extensive or ge- 
neral enumeration of the epidemics whose histories have been 
preserved. 

It has been said, that the visiiaiions of the disease, in New 
Orleans, had shown a tendency to observe alternate years ; but 
an examination of the fects, as they have been published, during 
a continuous period of twenty-two years, from 1S22 to 1S43. 
both included, gives but little support to this suggestion. From 
1833 to 1841, the epidemic prevalence of the disease returned, 
with a good deal of regularity, on each alternate year ; but from 
1827 to 1830, ^nd from 1841 to 1843, the disease prevailed re- 
gularly every year. According to Dr. Simons, the first appear- 
ance of yellow fever in Charleston, was in 1690 or 1700. It has 
since occurred in the following years, to wit, — 1703, 1728, 1732. 
1739, 1745, 1748, 1753, 1755, 1792, 1794, 1795, 1796, 1797. 
1798, 1799, 1800, 1802, 1804, 1807, 1817, 1819, 1824, 1827. 
1828, 1830, 1834, 1835, 1838, and 1839.^ Dr. Catel says that 
Martinique was almost entirely exempt from the disease, except 
a few sporadic cases, from 1828 to 1838.^ 

" That the essential cause of yellow fever," says Dr. Dowler. 
" will ever be discovered, or, being discovered, wiU be controlled 
or prevented by human art, is altogether improbable. Its myste- 
rious cycles culminate, decline, and reappear. Charleston, deso- 
lated at the close of the seventeenth century, was exempt in the 

^ N. O. Med and Surg. Jonm^ vol. i p. 418. 

* Am. Joum. Med. ScL, Feb.; 1S36, s Rapport, &:c.. par M, Clier-riD, p. 6. 



CAUSES.— SPORADIC. 465 

first quarter, but a sufferer in the second quarter of the eighteentli, 
and (hen, half a century of exemption again followed, — a period 
much longer than that which now cheers the cities of New York, 
Philadelphia, Boston, and Baltimore, with the hope that yellow 
fever has taken its leave of them forever. But the last decennial 
period of the past century, and the first of the present, relumed 
the tianies of the epidemic in Charleston, where they had smoul- 
dered so long, and in which they still continue to break out almost 
annually. Charleston suffered nearly a century in advance of 
New Orleans, and is still as great a sufferer as the latter."^ There 
is nothing in the past history of the disease, at all incompatible 
with the probability that the elliptical sw^eep of its epidemic pe- 
riods, may again bring it within the more northern cities, from 
which, for many years, it has been absent. 

Sec. XII. — Sporadic. Yellow fever, as I have just said, gene- 
rally prevails in the form of an epidemic ; but this is not always 
the case. It is now very well ascertained, that yellow fever cities 
are sometimes visited by isolated, sporadic cases of the disease. 
The question of the occurrence of the disease in this form w^as 
carefully studied by Louis and Trousseau at Gibraltar, in 1828. 
Mr. Amiel and Mr. Fraser communicated to them the histories of 
forty-five cases, derived from the hospital registers, which had oc- 
curred during non-epidemic seasons. Some of these cases, Louis 
regards as spurious or doubtful; but he is quite confident of the 
genuineness of the others. Dr. Gillkrest says, he is in possession 
of such a body of evidence, drawn from registers and other 
authentic sources at Gibraltar, as w^ould, of itself, place the mat- 
ter beyond all doubt. He adds, that in the month of April, 1829, 
the records of the civil hospital in that garrison were examined, 
and a certificate drawn up and signed by nine gentlemen, to the 
effect that thirty-eight cases, of which they found details duly re- 
corded in non-epidemic years, Avere identical in character with the 
cases which occurred there during the epidemic of 1828.^ Mr. 
Glasse, who was for a long time a resident at Gibraltar, says in a 
letter to Dr. Burnett, — " During the spring and autumn, I have 
been in the habit of seeing solitary cases of fever attended with 
black vomiting, and other severe symptoms."^ 

' N. 0. Med. Journ., vol. ii. p. 173. 2 Cyc. Trac. Med., vol. ii. p. 270. 

3 Burnett, p. 329. 

30 



466 YELLOW FEVER. 

Sec. XIII. — Marsh Miasmata. IMedical men who look upon 
yellow fever as only a high grade, or concentrated and malignant 
form, of bilious remittent fever, attribute the disease to the unknown 
cause or causes of the latter, called marsh miasmata, developed in 
unusual quantity, or endowed with extraordinary virulence. This 
is the opinion advocated by Dr. Bancroft, in his elaborate Trea- 
tise on the causes of this and other epidemic diseases; and by 
many others, who believe in the local and domestic origin of the 
disease. 

But the objections to this opinion are obvious and insuperable. 
In the first place, it is as well settled as any such question can 
be, that yellow fever differs, radically and essentially, from all the 
forms of periodic or marsh fever. The two diseases may prevail 
together, — as marsh fevers and small-pox, or typhus, may, — but 
this is rarely the case ; and in very extensive regions where pe- 
riodical fevers, in their worst forms, constitute the principal dis- 
eases, yellow fever is never seen. Again, in many yellow fever 
localities, there is no evidence, whatever, of the existence of 
marshes, or marsh miasms. Dr. Gillkrest says, — "It cannot be 
admitted that Gibraltar furnishes sources from which malaria, in 
the usual sense of that word, arises, sufficient to account for the 
appearance of a malignant fever."^ In 1844, yellow fever pre- 
vailed very extensively at Woodville, a small town in the interior 
of Mississippi. The town is built on a rolling ridge, three hun- 
dred and forty feet above the bank of the Mississippi river ; the 
soil is clay and sand ; the town is free from filth ; and there are 
no swamps or ponds in the neighborhood.^ The island of Barba- 
does is described as rocky and dry, with very little marshy or wet 
land.^ Brimstone Hill, in the island of St. Kitts, is a conical 
mount, rising to the height of seven hundred feet above the level 
of the surrounding plain. It is described as a volcanic rock, dry, 
nearly destitute of vegetation, and desolate in its entire aspect. 
It is generally free from yellow fever, but not uniformly so. In 
1811, and 1812, the disease appeared there, and was very fatal. 
Stoney Hill, in Jamaica, is thirteen hundred feet above the level 
of the sea. It is described as an entire mass of calcareous rock, 
covered with trees, excepting on the summit; but -with little soil, 
and producing scarcely any grass or herbaceous plants. It is ge- 

' Cyc. Prac. Med., vol. ii. p. 279. 2 X. 0. 3Ied. Jour., vol. i. p. 530. 

3 Rusli'sHillar>-,p.5. 



CAUSES.—ANIMAL AND VEGETABLE DECOMPOSITION, ETC. 467 

nerally healthy; but yellow fever does sometimes prevail, exten- 
sively and fatally, amongst the troops stationed on its summit. 
Furthermore, the frequent occurrence of the disease in ships at 
sea is entirely incompatible with the doctrine of which I am now 
speaking; and the whole subject may be fairly and definitively 
dismissed wdth an expression of surprise that the doctrine could 
ever have found any countenance or favor. 

Sec. XIV. — Decaying animal and vegetable matter. — Filth. In 
the almost interminable discussion which has been going on dur- 
ing the last half century, about the causes of yellow fever, there 
is no one element that has played a more prominent part, than the 
decay or decomposition of animal and vegetable matter. Most 
of the advocates of what is called the domestic origin of the dis- 
ease, and the deniers, at the same time, of its contagious proper- 
ties, have attributed it principally to this animal and vegetable 
decomposition; and to various local accumulations of filth, 
of one kind and another. It is w^ell known, that the dreadful 
Philadelphia epidemic of 1793 was referred, for its origin, by Dr. 
Rush, to a quantity of damaged coflTee, decaying on one of the 
wharves of the city. The principal argument in favor of this 
opinion, is the fact, generally admitted, that the disease most com- 
monly commences in the low, crow^ded, and filthy quarters of 
yellow fever cities, lying near the docks and wharves. Thus, the 
Barrio de Santa Maria is usually the hot-bed of the disease in 
Cadiz. In 1795, at New York, the disease was mostly confined 
to the vicinity of Peck-slip, a crowded and filthy locality;^ and 
the same thing has occurred in other years. Dr. Edward Miller, 
of New York, one of the earliest and most unqualified advocates 
of the agency of filth in the production of yellow fever, says, that 
at the commencement of the destructive epidemic of 1798, in 
that city, between twenty and thirty persons in a small neighbor- 
hood, at the lower end of John street, were suddenly seized with 
the disease in one night, in consequence of a blast of putrid and 
most oflfensive exhalations from the sewer of Burling slip.^ 

On the other hand, the agency of this cause is stoutly and 
boldly denied, by many observers, and especially by those w^ho 
believe in the contagious property, either qualified or absolute, of 

' Hosack's Med. Essays, vol. i. p. 293. 2 Works of E. Miller, M. D., p. 98, 



468 YELLOW FEVER. 

the disease. The principal objections to this doctrine are these. 
In the first place, it is asserted, and not denied, that yellow fever 
has sometimes made its appearance, and prevailed extensively, in 
localities quite free from any unusual accumulations of filth, either 
animal or vegetable. In the second place, it is quite notorious, 
that although the disease, oftener than otherwise, commences in 
filthy localities, still it very frequently extends to the more airy 
and cleaner neighborhoods. In the third place, if the disease was 
generated from this source, it ought to occur with more regularity 
and constancy; since the alleged cause is always more or less 
extensively present and active, in some portions of all yellow^ fever 
cities, and of others, w^here the disease is never seen. It seems 
to me, that these objections are quite unanswerable. Yellow fever 
occurred on board the United States schooner Grampus, in 1829. 
Dr. Barrington says, — " This vessel was remarkable for her uni- 
form neatness and cleanly appearance throughout. The bilge 
w^ater smell was seldom perceived; the water coming out of the 
pumps perfectly clear. "^ Several similar instances are mentioned 
by Dr. John Wilson. In 1824, the disease prevailed extensively 
on board the Rattlesnake, a new British ship, on the West India 
station. She had just been thoroughly cleaned. Dr. Wilson 
says, — "When the process of purification was considered com- 
plete, I examined every part of the hold's surface, and found it in 
every part, from the hatches to the kelson, clear, clean, and dry, 
scarcely capable of soiling a white glove." It is proper to state, 
however, that in most instances of the occurrence of the disease 
on ship board, it has been in connection with very damp and filthy 
holds. I do not mean to say that accumulated and concentrated 
filth, acted upon by a high temperature, does not promote and favor 
the origin and spread of yellow fever; there is good evidence that 
it does so ; I mean merely to say that we have no suflficient 
grounds for referring the disease directly and exclusively to this 
cause. 

In connection with this subject, it may be mentioned that Dr. 
John W^ilson, apparently an attentive observer of yellow fever, and 
generally a sensible writer, is disposed to refer the disease to a 
peculiar kind of ligneous decomposition, for its essential cause. 
He thinks this hypothesis corresponds to all the observed facts in 

» Amer. Jour. Med. Sci., Aug., 1833. 



CAUSES.— CONTAGION. 469 

connection with the subject, better than any other. ^ I cannot see 
that it is any more plausible, or any more reasonable than the 
rest. 

Sec XV. — Contagion. Let me relieve the friendly and indulg- 
ent reader who has accompanied me, cheerfully and not without 
interest, I would fain hope, thus far, in my history of yellow fever, 
from an apprehension that he may very naturally feel, on be- 
holding the caption of the present section in my manifold chap- 
ter on the etiology of this disease ; — it is not my purpose to oc- 
cupy his time and attention with anything like a history of the 
multiform, complicated, and sometimes bitter controversies, which 
have run through the medical annals of the last fifty years, upon 
the contagious and non-contagious character of the disease. In 
conformity to the general design and arrangement of my book, I 
shall confine myself to a simple statement of the actual and posi- 
tive condition of our knowledge upon this subject; all which can 
be done, I think, in the space of a few pages. 

There have been three leading and principal doctrines, or opin- 
ions, upon the question before us, each of which I wish and will 
endeavor to state ; together wdth the grounds upon which it rests, 
as fairly and explicitly as I can.^ 

' Memoirs of the West Indian Fever, p. 139, et seq. 

'^ The great controversy between the contagionists and the non-contagionists origin- 
ated in the following circumstances. Towards the close of the last century, a pro- 
ject was formed in England for the establishment of a colony, — partly benevolent 
and partly commercial in its character. — on the island of Bulam, or Boullam, lying 
at the bottom of a deep bay, about fifty miles from the open sea, on the Western 
coast of Africa, in the 11th degree of North latitude. Early in the month of April, 
1792, the ship Hankey, in company with another vessel, loaded w-ith stores and 
adventurers, sailed from England for Bulam, where she arrived just before the com- 
mencement of the rainy season. The Hankey remained at the island nine months ; 
soon after her arrival, a malignant disease appeared amongst her passengers and 
crew, consisting of more than two hundred persons, three-fourths of whom were its 
victims. Aided by a few seamen procured from other ships, the Hankey finally 
sailed for the West Indies, and arrived at Grenada, on the 19th of February, 1793. 
According to Dr. Chisholm, the first person who visited the Hankey, on the even- 
ing of her arrival, was a Captain Remington ; and in a few days afterwards, he 
died with yellow fever. The crew of the Defiance were the next who visited the 
Hankey; five out of six were immediately seized with the fever, and died in three 
days. The disease now begxm to appear in the other vessels, in the harbor, and 
spread successively from one to another, not one escaping. Until the middle of April, 
the disease was confined to the shipping in the harbor ; it then appeared in a house close 
to tiie wharf, where it was introduced, according to Dr. Chisholm, by a negro wo- 



470 YELLOW FEVER. 

The first of these doctrines is that, which attributes to yellow 
fever an absolute and unqualified contagious character. The ad- 
vocates of this doctrine allege, that the disease is directly and im- 
mediately transjuissihle from one person to another, like measles, or 
small-pox. Dr. Chisholm, one of the earliest and most zealous 
promulgators of this doctrine, thus states the leading circum- 
stances which influence the action of the contagious poison; — 
those who most carefully avoid houses, where the infection is, are 
the most certain to escape the fever; although the disease maybe 
in the same house, avoiding the chamber of the sick prevents in- 
fection ; merely entering the chamber of the sick, without nearly 
approaching the diseased person has never communicated infec- 
tion ; approaching near enough to the diseased person to be sen- 
sible of the fetor of his breath, or of the peculiar smell which is 
always emitted from the bodies of the sick in this disease, or 
touching the bed-clothes generally occasions nausea, slight rigors, 
and often headache at the moment, and, some hours after, the dis- 
ease itself; actual contact, so that the perspired fluid of the sick 
person may adhere to the hands or other parts, of the healthy 
person, more certainly produces the fever; touching the wearing 
apparel of a person, who is actually diseased, or has just reco- 
vered from the disease, as certainly communicates the infection 
to the healthy person, and finally, merely passing a person in- 
fected, or who wears the clothes he had on during the existence 
of the disease, in such a manner that the effluvia, proceeding from 

man who took in sailors" clothes to Avash. The disease then extended to different 
parts of the town, and during the months of May, June, and Jvily, it appeared at 
various points in the neighboring country, carried thither, says Dr. Chisholm, by 
persons who had imprudently visited infected houses in town. From Grenada, as 
from a focus, this nova pestis, — this new Malignant Pestilential Fever of Dr. Chis- 
holm spread to the other islands, to Jamaica, St. Domingo, and Philadelphia, — the 
infection being generally carried from place to place in the woollen jackets of de- 
ceased sailors. — Chishohn's Essay, voL i. p. 102, et seq. Dr. Chisholm attributes the 
introduction of the disease into Philadelphia, not to the damaged coffee, but to some 
sailors sick with yellow fever, on board the same vessel that brought the coffee, as 
part of its cargo. — Ibid., vol. i. p. 220. Dr. Chisholm, it is important to state, looked 
upon this fever as quite unlike the ordinary remittent yellow fever, as he called it, of 
the West Indies; the latter, he admitted, was of domestic origin, arising from mias- 
mata, endemic, and not contagious. The former, he says, may have owed its pro- 
duction, in some instances, to the united action of pestilential contagion and the 
miasmata of marshes, and other direct causes of yellow remitting fever. — Ibid., vol. 
i. p. 208. This is the doctrine of contingent contagion, of which I shall speak more 
fully by and by. 



CAUSES.— CONTAGION. 471 

them may be blown on the heahliy person, has produced the dis- 
ease.^ 

It may be interesting to my readers, while it will best illustrate 
the subject before us, to be made acquainted with some individual 
facts which tend to support the above-mentioned doctrine. Sir 
Gilbert Blane, in a letter to the Hon. Rufus King, relates the fol- 
lowing occurrence. "On the 16th of May, 1795, the Thetis and 
Hussar frigates captured two French armed ships from Guada- 
loupe, on the coast of America. One of these had the yellow 
fever on board, and out of fourteen men sent from the Hussar to 
take care of her, nine died of this fever before she reached Halifax 
on the 28th of the same month. Part of the prisoners were re- 
moved on board of the Hussar, and though care was taken to 
select those seemingly in perfect health, the disease spread rapidly 
in that ship, so that near one-third of the whole crew was more 
or less affected by it.*'- It is greatly to be regretted, that the cir- 
cumstance thus related, by Blane, like so many others of a simi- 
lar character, should be, in many respects, so loose and defective. 
The previous history of the Hussar is not given ; we are not told 
upon whose authority the entire narrative rests ; and nothing con- 
clusive is stated as to the real character of the fever on board the 
Hussar. A similar occurrence is related amongst the documents 
submitted by M. Chervin to the Royal Academy of Medicine. 
According to M. Lemarinier, in October, 1808, the French brig 
Paulinurus, of w'hich he was surgeon, attacked and captured, 
near Barbadoes, the English brig Carnation. The yellow fever 
was prevailing on board the Paulinurus at the time. The Eng- 
lish prisoners were most of them placed on board the latter, and 
nearly all of them had the fever. The day after the capture, M. 
Jance, commander of the Paulinurus, at the time mortally sick 
with the disease, was carried on board the Carnation, where he 
died on the following day. M. Lemarinier and a portion of the 
French crew were also transferred to the prize. The yellow fiver 
immediately appeared amongst the crew of the Carnation^ who had 
had no direct communication with the Paulinurus. Several of 
them died.^ Matthew Carey says, — " Since the first edition ap- 
peared, I have had information from a number of creditable per- 

' Chisholm's Essay, vol. i. p. 309, 2 Blane"s Dis. of Seamen, p, 605. 

3 Rapport de I'Acad. Roy. de Med., p. 8. 



4T2 YELLOW FEVER. 

sons, that the idea that the disorder has not been communicated 
out of Philadelphia, is erroneous. A family, of the name of Hop- 
per, near Woodbury, took it from some of our infected citizens, 
and three of them died. A woman in Chester county, who had 
boarded and lodged some of the sick, died of the malignant fever. 
Three people, of one family in Trenton, took it from a sick person 
from Philadelphia, and died of it. A negro servant, belonging to 
Mr. Morgan, took up an infected bed floating in the Delaware, 
which spread the disorder in the family, and Mrs. Morgan and 
her girl both died of it. It was introduced by his son from Phila- 
delphia into the family of Mr. Cadwallader, at Abington, some of 
w^hom died with it. Some others in different places caught the 
infection and died. But the cases of this kind have been ex- 
tremely few, considering the numbers, who carried the disorder 
from hence, and died with it in the country."^ I may dismiss 
this branch of the subject with the remark, that cases even o^ ap- 
parent communication of the disease, directly from one person to 
another, in an uninfected district, and without the aid of fomites, 
are exceedingly rare; and it may reasonably be doubted whether 
a single such case, of entire and unquestionable authenticity, has 
ever been known. 

The second doctrine upon this subject is in direct and positive 
opposition to the foregoing. Its advocates deny that yellow fever 
is, ever or under any circumstances y transmissible, by a contagious 
poison, from one person to another. They allege, that it is strictly 
endemic, in its origin and character, and absolutely non-con- 
tagious, like ordinary remittent fever. The general ground, upon 
which they rest this opinion, is the fact, almOvSt universally ad- 
mitted, that the disease, in a pure atmosphere, is manifestly and 
unequivocally not communicable from one individual to another. 
They say, further, that the disease can never be traced from one 
person to another, or from one family to another, — its extension 
depending upon personal intercourse; — that its extinction by cold 
weather is an argument against its contagious quality; and that 
the inconsistencies and contradictions which constantly attend 
the application of this doctrine render it altogether inadmissible. 
Since the beginning of the great controversy on this subject, in 
1793, a large proportion of observers, — both amongst private 

' Carey's Account, &c., p. 81. 



CAUSES.— CONTAGION. 473 

practitioners and writers, — at least in the United States and Great 
Britain, — have ranged themselves in the ranks of the non-con- 
tagionists. Amongst the earliest and ablest champions of this 
doctrine, in our own country, were Dr. Caldwell — still living, — 
Dr. Edward Miller, Dr. E. H. Smith,^ and Dr. Rush. Dr. 
Deveze,^ however, preceded them all; and his merits, in this re- 
spect, have been most strangely and most unjustly overlooked. 

In the third place, there is a doctrine holding a sort of middle 
ground between the two extreme opinions which I have just 
stated. This has been called the doctrine of qualified^ or con- 
tingent, contagion. It is held under somewhat modified forms by 
its different advocates ; but its fundamental principles may be 
thus stated. Yellow fever is a disease, which, in a pure atmo- 
sphere, or in an atmosphere not already in some way altered or 
vitiated, is not ordinarily or readily communicated from one per- 
son to another. Again, yellow fever is a disease which is not 
generally of spontaneous or domestic origin, in the localities 
w^here it prevails; at least this is true of many of these localities. 
But in places where the atmosphere has already undergone the 
unknown alteration or vitiation, of which I have spoken, prepar- 
ing those who have breathed it for the action of the poison of yel- 
low fever, the introduction of this poison, in the persons of those 
sick with the disease, in the hold of a ship, in fomites, or in any 
other form, will give rise to the disease amongst the inhabitants 
of this locality. The predisposition, or liability, created by the 
local vitiation of the atmosphere, is spoken of as the combustible 
element, or material ; the poison of the disease, introduced from 
without, is spoken of as the spark that lights upon and fires the 

1 Dr. Smith was one of the editors of the Medical Repository. He was one of the 
victims of the New York epidemic of 1798. Dr. Miller's brother and biographer 
pays the following tribute to his memory. ''Never can the writer of these lines 
forget the funeral of Dr. Smith. It was when the ravages of pestilence had be- 
come so tremendous as to drive almost every individual from the city who was able 
to fly; when scarcely any passengers were to be seen in the streets, but the bearers 
of tlie dead to the tomb; and when it appeared as if the reign of death must be- 
come universal; it was in circumstances such as these, that Doctors Mitchill and 
Miller, accompanied with two or three other friends, bedewed with their tears, and 
followed to the grave, the remains of a young man, in some respects the most 
enlightened and promising that ever adorned the annals of American Science." — 
E. Miller's Works, p. Ix. 

2 Amer. Journ. Med. Sci., vol. iv. p. 523. 



474 YELLOW FEVER. 

former. Neither of these conditions alone, it is alleged, is suffi- 
cient for the generation of the disease.^ 

The above was an early and a favorite doctrine with some of 
the most distinguished physicians of the city of New York. Dr. 
Seaman, as long ago as in 1795, laid it down, in the following 
terms: — "The general cause of yellow fever, as it appeared in 
this city, is what chemists call a tertium quid, neither one thing 
nor the other, but a result of the junction of certain matters, 
emitted from a human body, laboring under such a disease, with 
the effluvia arising from vegetable substances in a state of putre- 
faction. These putrid effluvia may, possibly, of themselves, 
generate the disease, in persons highly predisposed, and from 
w^hom, by their assistance, the fatal epidemic may be spread 
through a neighborhood. The spark that has kindled up the 
putrid vapors, in certain parts of our city, into action, was, most 
probably, originally introduced from other places. No yellow fever 
can spread but by the influence of putrid effluvia."^ The same 
doctrine was adopted, and both ably and earnestly advocated, by 
Dr. Hosack. He classes yellow fever with the plague, dysentery, 
and typhus fever; all which, he says, are rarely communicable 
from one person to another, except through the medium of an im- 
pure atmosphere. The yellow fever, he says, was always intro- 
duced into New York, from abroad, and then spread through the 
aid and agency of this vitiated local atmosphere. His favorite 
idea is that of 2. fermentative process, both in the atmosphere and 
in the human body, by which the specific virus of the disease is 
multiplied ; the fermentahle materials, as he calls them, — by 
which he means the unknown vitiation of the atmosphere, — and 
the specific virus, being, both of them, necessary, to the produc- 
tion of the disease. Dr. Hosack's precise notion seems to be 
this, — that the virus, introduced into the local atmosphere, already 
vitiated with his fermentable materials, excites and sets up in this 

^ It is proper to state, that even Dr. Chisholm, the great champion of the con- 
tagiousness of yellow fever, explicitly recognizes the agency of the predisposing 
cause. It is conceding nothing, he says, to admit, that at the time the infection of 
the malignant pestilential fever of 1793 was imported, something peculiar, and 
capable of predisposing the human body to be acted on by its poison existed in the 
air ; or that, in other words, the atmosphere possessed a peculiar constitution. But 
this is true, he adds, of the plague ; and he denies that this constitution is ever 
sufficient, of itself, to give rise to the disease. — Chisholnis Essay, vol. i. p. 286. 

2 Med. Rep., No. 3, Art. 2. 



CAUSES.— CONTAGION. 475 

atmosphere an assimilative process, by which the specific poison 
is indefinitely multiplied, — and after this assimilative process has 
taken place, the medium has been created, through which, the 
disease may be transmitted from one person to another. He al- 
leges, however, that in a few rare instances, yellow fever has 
been communicated directly, from the sick to the well, in a pure 
atmosphere.^ Dr. Hosack does not believe that animal and vege- 
table decomposition, or filth, alone, with all the accessories of 
heat, moisture, and a stagnant atmosphere, is sufficient, ordinarily, 
to generate the disease. 

The qualified doctrine of contagion is more or less admitted, I 
think, by nearly all the contagionists. Sir James Fellowes says, 
— " The facts recorded in the preceding reports show, that the 
disease was highly contagious in Spain, but this property seemed 
to depend on a certain temperature which is necessary to the ex- 
istence of the disorder, and a combination of circumstances, 
connected with individual predisposition and the climate, which 
although difficult to define, may be comprehended by those who 
have resided in that country, and who have studied the character, 
habits, and mode of life of the inhabitants."^ 

There are some of the non-contagionists, also, who admit at 
least the possibility of this occasional and contingent contagion. 
Mr. Doughty, a very decided and earnest non-contagionist, says, 
— "I am not prepared to say, whether a great number of persons, 
laboring under yellow fever, in its violent form, and crowded into 
an ill ventilated apartment, or circumscribed space, as on board 
ship, might not create a morbid atmosphere, of power sufficient to 
produce fever sui generis. At least, the atmosphere, impregnated 
w^ith a general cause, might be rendered more virulent by the ac- 
cumulated effluvia arising from numerous bodies laboring under 
the disease. As, for instance, a person exposed to the exhalation 
from the earth, or any other miasma, which has created fever in 
several, but, whose susceptibility to its influence being less, has 
escaped, may, by the further exposure to the accumulated effluvia 
of many bodies, affected with the disease, have febrile action pro- 
duced.^ Dr. Robert Jackson, another non-contagionist, thus 
speaks of the same subject. "I hold it to be proved, by the 

' Hosack's Med. Essays, vol. i. p. 253, et seq. 

2 Reports, etc., by Sir J. Fellowes, p. 402. 

3 Doughty 's Observ., p. 209. 



476 YELLOW FEVER. 

histories here alluded to, that fevers, except those specifically 
contagious, rarely propagate from person to person in tropical 
climates, but I do not deny the possibility of the contingence. 
If men, either in health or sickness, be crowded into damp and ill 
ventilated apartments, particularly in bomb-proofs, as sometimes 
happens in time of war, from conditions of service, or in time of 
peace, from want of barrack room, the air is contaminated by the 
emanations of a crowd of inhabitants." A material. Dr. Jackson 
thinks, may thus be contingently generated possessing the power 
of self-propagation.^ In another place, he says, that in this way, 
" contagion may sometimes be engrafted on the epidemic stock." 
Even Dr. Rush, one of the most strenuous advocates of the do- 
mestic origin of yellow fever, admits, -also, that the poison may 
sometimes be introduced from abroad. At least he records, 
without any qualifying remarks, several such instances. The 
fever of 1797, at Philadelphia, he says, w^as derived from the foul 
air of a ship which had just arrived from Marseilles. A ship from 
Hamburg, he adds, communicated the disease, by means of her 
foul air, to the village of Kensington.^ 

This particular form, or modification, of the doctrine of conta- 
gion, has been recently revived, if I may so speak, in our own 
country. It has been advocated with earnestness and ability by 
Dickson, Strobel, Monette and others, and at least with a certain 
degree of success, since it has given rise, in some instances, to 
quarantine regulations. It is a point in the history of yellow fever 
of great interest and importance ; — to be finally settled only by 
careful and repeated observations, and my notice of it w^ould 
justly be considered imperfect without some of the evidence on 
which the opinion rests. Amongst this evidence, are a considera- 
ble number of individual facts, like the following. In June 1823, 
a Spanish brig sailed from Havana to Passages, a small secluded 
sea port on the shores of the Bay of Biscay, consisting mostly of 
a single street, placed, as it were, on a shelf of scarped rock, and 
so narrow, that it does not admit of the passage of carts or horses ; 
while the rock forming the basis of the mountain is in some places 
literally in contact with the houses, which are badly ventilated, 
filthy, dark, and crowded. The vessel arrived on the 3d of 
August. On the 15th, a custom-house officer, who had been 

* Jackson on Febrile Diseases, vol. i. p. 31. 
2 Rush's Med. Inq., vol. iii. p. 3. 



CAUSES.— CONTAGION.— FOMITES. 477 

several days on board, and who was said to liave been much en- 
gaged in the hold, looking after contraband goods, was taken ill, 
and died on the third day, with black vomit. On the 22d, a man 
who had been down for some time in the hold surveying the 
ship's timbers died. Some of the planks of the vessel having 
been found decayed, twelve carpenters were employed in remov- 
ing them, and six of the twelve were attacked in quick succession. 
The opening in the side of the ship commenced on the 19th, and 
on the 23d, the disease began to appear in an unequivocal form in 
the houses close to which sheiuas moored. The disease was almost 
entirely confined to the immediate vicinity of the brig.^ 

Dr. Monette has given an account of the occurrence of yellow 
fever at Washington, Mississippi, in the autumn of 1825. This 
was then a small inland town, six miles east of Natchez, contain- 
ing about two hundred and fifty inhabitants, of whom nearly one- 
half were blacks. Its situation is described as elevated, free from 
marshes, free from filth, and the houses not crowded. It has been 
proverbially heahhy ; and the citizens of Natchez have been in 
the habit of fleeing thither for safety, on the appearance of yellow 
fever in their own city. Towards the last of August 1825, cases 
of the disease were officially reported in Natchez, and a great 
many merchants crowded into Washington, carrying with them 
household furniture and all kinds of goods and groceries. Several 
deaths soon took place in Washington amongst the fugitives from 
Natchez. Ten or twelve days after the flight from JYatchez, 
deaths from yellow fever began to occur amongst the inhabitants 
of Washington. Two of the persons, amongst those first at- 
tacked, lived together in a house entirely isolated, two hundred 
yards from the main street, in an elevated and clean spot; they 
were carpenters, and had been at work shelving rooms for the 
merchants from Natchez, and assisting them in opening and put- 
ting up their goods. The disease was malignant; cases occurred 
in all parts of the towm, and the people from Natchez again fled, 
accompanied by the citizens of Washington, to the surrounding 
country. One fourth of the white population fell victims to the 
epidemic. Dr. Monette asserts that in several well ascertained 
instances, cases of the disease occurred in the surrounding country, 
in persons who had not been in Washington, but who had been ex- 
posed to the blankets and bedding of those who had died of the 

1 Cyc. Prac. Med., vol. ii. p. 292. 



478 YELLOW FEVER. 

disease. The most striking case of this character is thus stated. 
"At a gentleman's house, two miles from Washington, two of his 
relations, after being removed thither, died of yellow fever. The 
bedding on which they had lain w^as thrown together into an upper 
room, where it remained several days. In this place it was 
found by three small girls, who for two or three days, unknown 
to their parents, were in the habit of going into this room to play 
upon the bedding. In a short time all three of these children 
were attacked with well marked yellow fever, although the situa- 
tion has been noted for its salubrity, and they had no opportunity 
of contracting the disease elsewhere. These were the only per- 
sons in the family who suffered from the disease."^ These cases 
of Dr. Monette's seem to have been mostly referable to the action, 
not of direct personal contagion, but to that of fomites. This 
constitutes a local concentrated atmosphere of the poison ; and 
there is the most ample and conclusive evidence that it may be 
preserved for a long period of time in this way.^ 

Sec. XVL — Exposure ; fatigue ; excesses, Sfc. There can be 
no doubt that yellow fever is frequently the immediate result of 
the operation of the ordinary occasional or exciting causes of dis- 
ease; and that persons exposed to the essential poison of the dis- 
ease might escape, were it not for the co-operation of the latter 
influences. Still, it must be admitted, that the extent to which 
these causes act, in the production of the disease, has been only 
very loosely studied, and very imperfectly ascertained ; and, in 
many instances, the power of the endemic cause is so great and 
so overwhelming, as to stand in need of no assistance from acci- 
dental or collateral agencies. Dr. Barrington says, from all he 

1 West. Med. and Phys. Jour., vol. i. p. 73, et seq. 

2 It seems to have been forgotten, that even Dr. Rush distinctly admitted the 
possibility of this origin of the disease. He says, — " It is possible a portion of the 
excretions of the sick may be retained in beds or clothes, so as to afford an exhalation 
that may in the course of a succeeding summer and autumn, or from accidental 
warmth at any time, create a solitary case of fever, but it cannot render it epidemic. 
A trunk, full of clothes, the property of Mr. James Bingham^, who died of the yel- 
low fever in one of the West India islands, about fifty years ago, was opened, some 
months after it was received by his friends, by a young man who lived in his bro- 
ther's family. This young man took the disease and died ; but without infecting 
any of the family ; nor did the disease spread afterwards in the city. The father 
of Mr. Joseph Paschall was infected with the yellow fever of 1741, by the smell 
of a foul bed in passmg through Norris"s Alley, in the latter end of December, after 
the disease had left the city."' — Rush's Inq., vol. iii. p. 103. 



CAUSES.— EXPOSURE —EXCESSES, ETC. 479 

has seen, he is convinced, that the temperate man, as a general 
rule, has the best chance ; but he says, also, — and these are his 
words, — ** I have not observed that those who were accustomed 
to the regular and moderate use of spirituous drinks, were more 
obnoxious to attacks of fever, than others of rigidly temperate 
habits ; on the contrary, and I regret to say it, because it affords 
a pretext for the intemperate, in two or three instances, I have 
seen the abstemious carried off in a few days, while hard drink- 
ers, under the same exposure, have escaped."^ Dr. Rush, in his 
account of the fever of 1803, in Philadelphia, says, — " I did not 
see a single case in which the disease came on wdthout an excit- 
ing cause ; such as light clothing and bed clothes, sitting at doors 
after night, a long walk, gunning, and violent and unusual exer- 
cises of any kind."^ This observation would be of more value 
than it is, if Dr. Rush had been somew^hat more careful and discri- 
minating than he was, and less ready to jump blindly to general 
conclusions. Dr. Hillary, — that honest and careful old observer, 
— says : " The disease most readily seizes those who use vinous 
or spirituous liquors too freely ; and still more readily, those who 
labor hard, or use too violent exercise, and are at the same time 
exposed to the influence of the scorching rays of the sun in the 
day-time, and soon after expose themselves too suddenly to the 
cool dew^s, and damp air of the night, and especially if they drink 
spirituous liquors too freely at the same time."^ 

Sir Gilbert BJane, speaking of acute diseases generally, amongst 
Europeans newl}^ arrived in the V/est Indies, says, — " It cannot 
be too much inculcated on those who visit tropical countries, that 
exercise in the sun, and intemperance, are most pernicious and 
fatal practices, and that it is in general by the one or the other 
that the better sort of people, particularly those new^ly arrived 
from Europe, shorten their lives."'* Matthew^ Carey says of the 
Philadelphia epidemic, of 1793, — '^ To tipplers and drunkards, 
and to men who lived high, and were of a corpulent habit of body, 
this disorder was very fatal. Of these, many were seized, and 
the recoveries were very rare."^ Dr. Deveze, in his account of 
the same epidemic says, it has always been remarked, that during 
the prevalence of yellow fever, persons new^ly married are con- 

' Am. Journ. INIed. Sci., Aug. 1833. 2 Med. Inq., vol. iv. p. 58. 

3 Rush's Hillary, p. 107. ^ Diseases of Seamen, p. 132. 

5 A Short Account, etc.. p. 61. 



480 YELLOW FEVER. 

stantly its victims.^ " Of all the exciting causes of yellow fever," 
says Bally, "the act of coition is the most powerful ; how many 
have we seen, seized by a chill, on leaving the arms of Pleasure, 
terminate in a few days their career ! How many even, have we 
seen, the victims of a simple nocturnal pollution!"^ 

Sec. XVII. — Essential Poison. In regard to the essential poi- 
son, the application of which to the system gives rise to yellow 
fever, I can do but little more than to repeat the remarks that 
have already been made, in connection with the essential etiolo- 
gical poisons of other fevers. The nature and composition of 
the former, like those of the latter, are entirely unknown to us. 
It would seem to be clearly enough of terrestrial origin ; and not 
capable of being transmitted, to any considerable distance, through 
the atmosphere. Most of its ascertained properties and relations 
have already been indirectly stated; inasmuch as they are con- 
nected with the causes of yellow fever already detailed. It is 
quite unnecessary, and it would be a very thankless and unpro- 
fitable labor, to enumerate the successive hypotheses and specu- 
lations which have been started in regard to the origin, nature, 
and mode of action of this poison. The animalcular hypothesis 
seems to me more plausible and less refractory than the others ; 
but it is only a pure hypothesis. As to its mode of action on the 
system; the organs by which it is received, and so on, we are as 
profoundly ignorant, as we are of its nature and composition. It 
is probable that it is introduced into the system through the lungs; 
although this is merely a conjecture. It is entirely philosophical, 
to consider it as a peculiar poison, — an agent sui generis, — differ- 
ing from all others, like the essential poison of small-pox, hydro- 
phobia, and so on. A very short exposure to its influence is 
sufficient to produce the disease; it is very probable that a single 
inhalation is enough. It may be retained, for a considerable 
period of time, shut up in the holds of vessels, in trunks or bales 
of clothing, in bedding, and even in apartments of houses, while 
the surrounding atmosphere is free from it; in some of these 
forms, it may be transported long distances from the place of its 
origin, and there give rise to the disease. The only known means 
of destroying it consists in a temperature as low as the freezing 
point, and this is alw^ays immediate and complete in its operation. 

> Deveze, p. 114. ^ p^ Typhus d'Amerique, par Vr. Bally, p. 375. 



481 



CHAPTER V. 

VARIETIES AND FORMS. 

Sec. I. — Season and Locality. Yellow fever is not exempt from 
that very general law of pathology, according to w^hich endemic 
and epidemic diseases, especially, vary, more or less widely, in 
severity, and sometimes in other respects, in different periods, 
and in different localities. Sometimes, and in some places, the 
general character of the disease is mild, and the mortality small; 
at others, it is grave and malignant, and the mortality excessive. 
The disease varies also, in other respects, in different seasons and 
places, sometimes one element or tendency, and sometimes an- 
other, in its complex pathology, predominating. Thus the pre- 
vailing character of the disease may be, during one season, 
simple and mild; during another, violent and inflammatory; and 
during a third, adynamic and congestive. Similar differences 
have also been observed at different periods of the same epi- 
demic, in a given locality. It is a common opinion, indeed, that 
the commencement of an epidemic is usually marked by greater 
malignancy and severity than its subsequent periods. The causes 
of these fluctuations and differences in the severity and character 
of the disease are wholly unknown to us; there are no obvious 
or appreciable influences to which we can attribute them; and in 
the absence of all positive knowledge upon the subject, we are 
obliged to refer them to unknown and hypothetical constitutions 
of the atmosphere, and to differences in the quantity or quality 
of the essential remote cause of the disease. It is proper to say 
here, that although there can be no doubt about the existence of 
these differences, still their extent, degree, and frequency, have 
been less carefully studied, and less positively ascertained, than 
many other points in the natural history of this disease. There 
are, however, in addition to the general opinions of those who 
have been most extensively familiar with the disease, numerous 
31 



482 YELLOW FEVER. 

well ascertained and authentic facts bearing upon the question 
before us. 

3ec. II. — Forms, or Grades. Different writers upon yellow 
fever have divided the disease into forms, or varieties, more or 
less numerous, depending upon different degrees of severity, or 
upon the preponderance of certain groups of symptoms. The 
most common, and I think the most natural, of these groupings, is 
that which makes three forms, or varieties, of the disease, to wit ; 
First, the Simple or Mild form; Second, the Inflammatory form ; 
Third, the Congestive, or Malignant form. This sub-division is, 
of course, to a certain extent, arbitrary and conventional ; still, 
it is founded in nature, and it is both useful and convenient, on 
many accounts, in the description and history of the disease. It 
corresponds very nearly to the similar divisions in other epidemic 
diseases ; — to the simple, the anginose, and the malignant forms, 
for instance, of scarlet fever. 

The simple or mild form of yellow fever is marked by the 
smaller number of symptoms, than are present in the graver 
cases, and by their very moderate degree of severity. Most writ- 
ers make particular mention of this variety of the disease ; and 
it is very common during certain epidemics. Louis describes it 
in the following terms : — " Most commonly, at the commence- 
ment, there were headache, chills followed by a slight degree of 
heat, pains in the limbs, and redness of the face and eyes. The 
epigastric pains were rare, and so too were the vomitings, which 
were almost never spontaneous, and which in no case were of a 
brownish color. The heat and thirst w^ere moderate, and so slight 
was the diminution of strength, that the patients did not keep 
their beds at all, or were there for half a day only; thus, accord- 
ing to their expression, going through with the disease on foot. 
In this form of the disease, they were able to escape the vigilance 
of the health inspectors, resuming familiar occupations, or play- 
ing on musical instruments, when these last made their visits. 
In several of these cases, the febrile symptoms were very slight, 
continuing only during twenty-four or thirty- six hours. "^ Dr. 
Lewis, of Mobile, says : — " The attacks in the milder cases were 
occasionally so light and ephemeral, as to pass off in a few hours, 

' Louis on Yellow Fever, p. 175. 



VARIETIES AND FORMS. 483 

leaving the patient with some soreness of the muscles, and slight 
pain in the hips and legs. But, as a general rule, they confined 
the patient to his bed, for three or four days. After the chill, 
which was commonly of very short duration, the pain over the 
eyes, and in the back and hips, became for a short time intense. 
The flushed face, animated voice, and sparkling eye, which cha- 
racterized the febrile stage, have been aptly compared to the ex- 
citement produced by champagne. In a few days, the disease 
has run its course, and after it has done so, the patient is well; 
with a gentle perspiration, the momentary fretting of the nervous 
system passes rapidly away, without materially impairing or dis- 
turbing any of the organs."^ These mild cases occur most fre- 
quently amongst children, negroes, and natives, or those who 
have become more or less acclimated. During the prevalence of 
yellow fever at Gibraltar, in 1828, several persons, amongst whom 
w^ere some of the medical practitioners, took pains to expose their 
children to the causes of the disease, in order to secure them 
against graver attacks later in life. Dr. Gillkrest says, in epide- 
mics of ordinary severity, such mild cases may occur in the pro- 
portion of one to ten or twelve of the severer grades ; and their 
occurrence will usually be found more frequent, as the end of the 
epidemic season approaches.^ 

The open inflammatory form, as its name indicates, is charac- 
terized by the phenomena of frank febrile excitement. The local 
pains, especially those of the head, back, and limbs, are violent ; 
the skin is warm ; the pulse full and hard, and the thirst urgent. 
These symptoms continue for a day or two, and then gradually 
subside, giving place to convalescence ; or they are followed by 
the stages of calm and collapse, terminating in death. 

In the congestive or malignant form of yellow fever, the febrile 
excitement of the first period is either wanting, or only slightly 
marked; or, if present in any considerable degree, it is accompa- 
nied by certain phenomena indicative of the congestive element, 
and is soon followed by the gravest and most alarming symptoms 
of the disease. There seems to be a good deal of variety in the 
character of these cases. Sometimes the disease is in some de- 
gree latent, — its usual symptoms being either masked or absent. 
The walking cases, as they are called, belong to this variety. At 

' N. 0. Med. Joum., vol. i. p. 295. 2 Cyc. Prac. Med., vol. ii. p. 270. 



4S4 YELLOW FEVER. 

Other times, the disease is marked by a want of reaction, softness of 
the pulse, coldness of the surface, great restlessness and distress, 
a tendency to hemorrhage from different parts of the body, and 
rapid collapse.^ 

' Dr. John Wilson divides the disease into inflammatory^ and congestive: he then 
makes three grades of the former, — the mild; the violent ; and the intense: — and 
three of the latter, — the slight; the aggravated; and the apoplectic. These "varieties 
are thus described. " The most constant and prominent symptoms of the inflam- 
matory were, with or without rigor, frequency and strength of pulse, wiry, com- 
pressed, or full ; a hot, non-secreting condition of the skin, particularly at the prae- 
cordia, and across the forehead ; headache, co nfi ned generally to the sinciput, with 
sense of fullness in the eyes, and tightness between the temples ; jactitation, and 
constant rolling or otherwise moving of the head; flushing of face, with promi- 
nence, wildness, and sometimes inflammation of the eyes; pain in the back and 
loins, shooting across the anterior parietes of the abdomen, involving the whole 
contents in tumult." With these symptoms, there were also, insatiable thirst; high- 
colored and scanty urine ; and in some cases abdominal tension and tenderness in 
the early stages, followed by a sense of emptiness and exhaustion there as the 
disease proceeded. 

In the intense form he says. — '-The action of the carotids was tremendous; the 
face red, and frenzied in expression; the eye sometimes clear, quick, and piercing; 
sometimes dull, and darkly inflamed, always indicative of great cerebral derange- 
ment. The skin had an intensity of heat scarcely conceivable, particularly on the 
breast, neck, and head. The tongue was parched, hot, and apparently diminished 
in size.'' 

Of the congestive form he says. — " A sense of stupor, weight and oppression, rather 
than pain in the head ; a feeling of helpless debility. aSecting the spine, most dis- 
tressing about the sacrum ; a paralytic failure of the lower extremities, with pains 
in the knees and calves of the legs ; a pulse having all degrees of celerity and ex- 
pansion, but always weak, sinking under the finger without resistance ; a state of 
the skin various and difficult to define, but always deficient in tone, sometimes dry 
and dense, sometimes greasy, and sometimes drenched in sweat ; generally without 
increase of heat, except at the praecordia, where it was confined and smouldering ; 
a most distressing expression of countenance, deadly pale or livid in color ; a 
drunken idiotic eye, with dilated pupil and sleepy motion ; deafness ; desire to be 
left alone ; sighing, deep and interrupted ; early tendency to coma ; tension of the 
hypochondria ; and early irritability of stomach, were the principal symptoms by 
Avhich this division of the disease was characterized." 

The highest grade of the congestive form is thus described: — "The attack was 
like the efiect of electricity. In an instant, its subject was seized with giddiness, 
diTll pain of head, and confusion of ideas ; a sense of coldness, weakness, and in- 
describable uneasiness along the spine : spasmodic pains in the legs, and paralytic 
incapacity of the lower extremities. He lay as if stunned, and laboring under con- 
cussion of the brain, with dilatation of the pupils, and a gloomy despairing coimte- 
nance. The pulse was rapid or slow, full or small, but always weak. The skin 
was cold, generally greasy, or covered with cold liquid sweat, sometimes dry and 
lifeless." 

" There is a modification of congestive fever so insidious as to give little alarm, 



VARIETIES AND FORMS. 485 

Some writers have gone much further than this, and have alleged 
that several distinct diseases, or forms of disease, have been con- 
founded under the common name of yellow fever. The opinions of 
Chisholm upon this point are well known. Bally proposes to admit 
one species which is contagious, and another which is non-con- 
tagious. Deveze says, very properly, I think, in regard to these 
and all other like distinctions, that they are arbitrary and un- 
founded.^ 

and lead the inexperienced to think the patient is in no danger, Tlie person labor- 
ing under this form of disease will confess, on being sharply questioned, that there 
are slight pain and heaviness in the head, and the epigastrium is tender on pressure. 
Otlierwise little appears to be the matter, the pulse being natural, or so nearly natu- 
ral, as to escape observation; the tongue clean; the skin cool or obscurely hot over 
the stomach and liver; the eye clear; and the entire aspect, to superficial observa- 
tion, promising. Yet, in less than forty hours, the surgeon will be alarmed and 
confounded by black vomiting, soon followed by death. Although the patient will 
say, every time that he is visited, that he is better, and that, could he only eat, he 
would be well; on looking closely, it will be perceived that his answers do not 
always bear on the questions put; that amid his accounts of improvement, he never 
attempts to lift his head from the pillow till desired, and hurriedly lets it down 
again ; that he dozes rather than sleeps, sighs frequently, and has difficulty in 
filling the lungs; artd that the eye, though clear, is vacant, or fixed without an ob- 
ject." — Memoirs of the West Indian Fever^ p. 8, et seq. 
* Traite de la Fievre Jaune, Par Jean Deveze. 



486 



CHAPTER VI. 

MARCH AND DURATION. 

Sec. I. — March, or Type. Yellow fever does not belong to the 
class or family of periodical diseases; it is not properly remittent, 
nor intermittent, in its type; it is not marked hy any obvious and 
regular senes of recurrent phenomena. The periodical element 
in pathology may sometimes be engrafted upon it, or mixed up 
with it, as happens occasionally with other diseases; but the two 
affections are essentially and fundamentally dissimilar. Upon 
this point, most modern observers, I believe, are agreed, although 
many of the older writers maintained an opposite doctrine. This 
was the case especially with those who were zealously contend- 
ing for the domestic and miasmatic origin of the disease. They 
conceived the cause they were advocating to be strengthened by 
every analogy and resemblance which they could discover be- 
tween the two forms of disease ; and this inflaence led many of 
them to adopt the doctrine, that yellow fever is only an aggra- 
vated form, or a high grade, as they call it, of ordinary remittent 
fever. It is well known that this was the opinion of Dr. Rush. 
He says that in every case of the disease, which came under his 
notice, there were remissions or intermissions of the fever, or of 
such symptoms as were substituted for the fever, generally occur- 
ring in the forenoon, and that these remissions were more evident 
than in the common bilious fever. I think, however, that a care- 
ful estimate of Dr. Rush's remarks upon this subject, with the 
aid of subsequent and more accurate investigations, will lead to 
the conclusion, that his observations are not to be trusted. His 
description of the remissions is anything but clear and distinct ; 
and when we take into consideration the extent to which his 
judgment was perverted, and his vision blinded, by his prepos- 
terous dogma of the unity of disease, it can hardly be considered 



MARCH AND DURATION. 487 

unreasonable, if, in the settlement of this question, we set his 
opinions wholly aside. ■^ 

I have just stated that yellow fever, like other diseases prevail- 
ing in malarious regions, may sometimes assume something of a 
periodical character. This subject, deserving of further investi- 
gation, has recently been studied by Dr. Lewis, of Mobile. 

He has described a form of the disease, which he calls remit- 
tent^ and intermittent yellow fever. During the epidemic of 1843, at 
Mobile, simple remittent fevers prevailed extensively in the southern 
part of the city, mostly amongst the native and acclimated popu- 
lation. Dr. Lewis says, that he attended in this district of the 
city sixteen cases of remittent or intermittent fever, assuming the 
rank and grade of yellow fever. These cases were all amongst 
the unacclimated. Dr. Lewis estimates the number of these 
cases, during the epidemic of 1843, at one hundred; fifty of 
which terminated fatally. He says, the intermittents were more 
fatal than the remittents. With the exception of this periodical 
element, the disease in these cases did not differ from the ordi- 
nary unmixed forms of yellow fever; it went regularly through 
its several stages, and terminated in its usual manner, and at its 
usual periods. Of twenty- eight cases of fatal intermittent yellow 
fever, all terminated within the seventh day from the initial chill. ^ 
Dr. Lewis does not give any full description of these cases, but 
there is no reason whatever for doubting the correctness of his 
conclusions. He is a competent and trustworthy observer, and 
he is in no way influenced in his opinions by preconceived pre- 

1 Nowhere, perhaps, does Dr. Rush make a more absurd exhibition of this 
favorite article of his philosophical creed, than in connection with the subject of 
the text. " Science," he says, " has much to deplore from the multiplication of dis- 
ease. It is as repugnant to truth in medicine, as polytheism is to truth in religion. 
The physician who considers every different affection of the different systems in 
the body, or every affection of different parts of the same system, as distinct dis- 
eases, when they arise from one cause, resembles the Indian or African savage, 
who considers water, dew, ice, frost, and snow, as distinct essences ; while the 
physician w^ho considers the morbid affections of every part of the body, however 
diversified they may be in their form or degrees, as derived from one cause, re- 
sembles the philosopher who considers dew, ice, frost, and snow, as different mo- 
difications of water, and as derived simply from the absence of heat. Humanity 
has likewise much to deplore from this paganism in medicine. The sword will 
probably be sheathed forever, as an instrument of death, before physicians will 
cease to add to the mortality of mankind by prescribing for the names of diseases." 

2 N. O. Med. and Surg. Journ., vol. i. p. 292. 



488 YELLOW FEVER. 

judices or notions, since he recognizes, without any qualification, 
the essential dissimilarity of periodical, and yellow, fever. In 
another paper. Dr. Lewis mentions particularly seven cases, 
occurring in 1842, which he calls congestive, simulating yellow 
fever. They occurred in persons who had been living in malari- 
ous regions; and were marked by the symptoms of congestive 
and of yellow fever. Dr. Lewis says, "The pathological appear- 
ances of the congestive fever of the interior, and the yellow fever 
of Mobile were both apparent in these cases, sO that, taken in con- 
nection with the symptoms before death, they constituted a perfect 
example of the blending together of the different febrile poisons, 
so as to produce a disease of mixed character."^ Other diseases 
are frequently mixed up with this periodical element in pathology ; 
and not only is there no reason a priori why such should not 
sometimes be the case with yellow fever, but it would be a very 
singular circumstance if this disease alone should be exempt from 
this complication.^ 

It is hardly necessary to say, that the distinction which Chis- 
holm attempted to establish between what he called Malignant 
Pestilential Fever, and the Yellow Remittent Fever of the West 
Indies was wholly gratuitous and unfounded. Lempriere, also, 
admitted the existence of a distinct disease, in the West Indies, 

1 N. O. Med. Journ., vol. i. p. 35, 

2 I find, since writing the above, that Lempriere, towards the close of the last 
century, noticed particularly this modification of yellow fever, in Jamaica. He 
calls it "a variety of the disease grafted upon the remittent^'' "Tn this," he says, "the 
first attack is marked by the usual symptoms which usher in the remittent, except 
that the affection of the head is more severe, and the eyes wear a suspicious ap- 
pearance; remissions and exacerbations proceed alternately as in the common 
remittent, and bark in large doses is generally retained during the remissions, from 
which the inexperienced are wont to draw favorable conclusions; but about the 
third or fourth day, and sometimes later, such symptoms occur as denote the 
greatest danger; the eye becomes muddy and suffused, the countenance despond- 
ent, and the neck, and afterwards the whole body, shows itself dyed with a yellow 
suffusion ; great irritability of stomach, and oppression about the precordia, delirium, 
or more frequently coma, and many other symptoms of the genuine yellow fever, 
supervene.'" — Observations, etc., by Lempriere, vol. ii. p. 70. Dr. Dickson, formerly of 
Charleston, S. C, now in the University of New York, admits explicitly and distinctly, 
the existence of this modified form of yellow fever. "In the summer of 1817," he 
says, " many northern and foreign sailors had been induced to go as boatmen up our 
rivers. Considerable numbers of them were brought into our hospitals with coun- 
try fevers, both remittent and intermittent, which, as soon as yellow fever became 
prevalent, ran into that epidemic, — the fever becoming contiiiued, and black vomit 
ensuing." — Dickson s Essays, ^c, vol. i. p. 335. 



MARCH AND DURATION.— STAGES. 489 

usually showing itself in crowded ships, partaking of the charac- 
ter both of yellow and typhus fever, and, like the latter, conta- 
gious. It seems to me quite clear, that this disease was only the 
malignant or congestive form of true yellow fever. -^ 

Sec. III. — Stages. But although there is no regularly recur- 
rent or periodical element in yellow fever, the disease, in fatal 
cases, is marked by several very constant and striking stages^ or 
periods, through which it passes with great regularity. These 
stages, or periods, are three in number, to wit: — first, the febrile 
period, or the stage of excitement; — second, the passive stage, or 
remission, or the stage of calm, as Dr. Lewis calls it; and third, 
the stage of collapse. The first stage is marked by general febrile 
excitement, and it passes into the second with an abatement of 
the severity of the local pains, and of the fever. The second 
stage is marked, in addition to the change of symptoms, just 
spoken of, by epigastric distress, nausea, and vomiting, and gene- 
ral restlessness, the latter commonly paroxysmal. The third 
stage usually commences with the black vomit, and is imme- 
diately followed by coldness of the extremities, yellowness of the 
surface, general sinking of the powers of life, and speedy death. 
In grave cases, terminating favorably, the period of remission, 
instead of passing into the stage of collapse, is followed by con- 
valescence; and in the milder forms of the disease, it can hardly 
be said that there are any of the distinct stages, except the first. 
Dr. Lewis says, — " The collapse stage is more marked and regu- 
lar, some years than others. In 1837, it was irregular; in 1839, 
it seldom failed to occur on the night of the fourth day, attended 
with immediate and striking evidences of sinking prostration ; in 
1843, it occurred between the beginning of the fourth and sixth 
day of the disease."^ The duration of these several stages will 
be found, of course, to vary considerably in different cases and 
under different circumstances. The most positive information 
that I am able to find upon this point is derived from Dr. Lewis. 
*'I have taken," — he says, — " twenty cases of epidemic fever, in 
which all these stages were well defined, — the notes of many of 
them furnished by medical friends, — and after a careful ex^mina- 

* Observations, etc., by Wm. Lempriere, vol. ii. p. 80. 
2 N. 0. Med. and Surg. Jour., vol i. p. 298. 



490 YELLOW FEVER. 

tion, I ascertained the average duration of each stage to be as 
follows :— fever ^ twenty-two hoars ; calm,, one hundred and twenty 
hours; collapse, fourteen hours,"* Dr. Lewis says that in the 
fever of the present year — 184T — :.r ir ri.e s^:ge is considerably 
longer; running on generally j : : :;r \^ Dr. Dickson 
says this stage may pass by i:: : ;ars, or it may last for sixty 

cr Srve::^ : its average duratici: :: _ irr^ra thirty-six to forty-eight. - 
Ti-r - rr stagcs of yellow iz"--': : r t y well described by Dr. 
Chisholm: "The history of :: : _ rstilential fever,"— 

he says, — " exhibits a very ci; i .^ ; _ racter. We see in 
it a disease dispossessed of & .tI :. t ; :; :r.s and remissions : 
and having, in its progress, three distinct periods or stages : the 
first characterizing an inflammatory diathesis of a peculiar nature, 
ushered in, generally, by a convulsive affection of the frame, or a 
sudden morbid excitement of the nervous system; — the second, a 
kind of suspension of all the animal fiinctions, accompanied with 
a more or less imperfect exercise of the mental faculties ; and the 
third, a general sphacelus of the vital organs."^ Dr. Mosely also 
makes the same division, and he speaks of the " deceiving iran- 
qmllUy" of the second stage. In relation to the treatment, he 
remarks, that " it is in the beginning of this second stage, when 
attempts have failed, or have been neglected, in the inflammatory 
stage, that the erreat struggle is to be made between life and 
death. "^ Lr re takes pains to call the disease 3. continued 

fever. Dr. £_.„;:: says, — "In many instances it proceeds 
through its whole course, bearing strictly the form of a continued 
fever; in others, there is a deceitfid remission about the third 
day. But in by far the greater number of cases, though there are 
evening exacerbations, the remissions in the morning are so slight 
as scarcely to deserve that name. The most attentive observa- 
tion, by myself, and others on whom I coidd rely, has failed to 
detect the distinct remissions ascribed to the disease by Dr. Cleg- 
horn."^ 

According to Bally the duration of the first stage, in cases that 
are prolonged to the seventh day, varies from forty-eight to 
seventy-two hours ; in cases terminating before the fiith day, it 

* M. O. Med. and Surg. Joor, voL L p. 301. » 

« Dickson's E^ays, &e, toL L p. 348. » Chisholm's Essay, voL L p. 195. 

* Moselj on Tropical Diseases, p. 436. s Samett oa Med. Fever, p.lO. 



MARCH AND DURATION.— CONVALESCENCE. 491 

is less : that of the second stage is about two days, — a little more 
or a little less; and that of the third, from one to two days.^ 

Sec. IV. — Duration. Yellow fever is rapid in its progress, 
and short in its duration. Perhaps there is no disease, excepting 
contagious puerperal fever, and Asiatic cholera, which terminates 
with such uniform rapidity, either in death or recovery as this. 
Life is sometimes destroyed in three or four days, and the average 
duration of fatal cases is less than a week, the largest number of 
deaths taking place on the seventh day, but many more cases ter- 
minating before this period than after it. Of twenty-one fatal cases, 
reported by Dr. Barrington, death took place on the third day, in 
one; on the fifth day, in six; on the sixth day, in three; on the 
seventh day, in eight ; on the eighth day, in one ; on the thirteenth, 
in one, and on the twenty-eighth, in one.^ Dr. Lewis says, that 
during the epidemic of Mobile in 1843, it was not uncommon to 
hear of persons who were w^ell in the morning and dead at night; 
but that these reports were always untrue, the disease never de- 
stroying life so rapidly. 

Dr. Barton in his paper on the yellow fever of New Orleans, in 
1833, gives the period of discharge from the hands of the physi- 
cian in sixty-eight cases of recovery. This period was the second 
day, in four ; the third, in ten ; the fourth, and fifth, in fourteen 
each; the sixth, in ten; the seventh, and eighth, in four each; 
and after the eighth, in eight. Of forty-four cases, where the 
time of the returns of appetite was ascertained, this took place on 
the second day, in one; on the third, in seven; on the fourth, and 
fifth, in fourteen each ; on the sixth, in seven, and on the eighth, 
in two.^ The duration of the mild form of the disease is still less. 

Sec. V. — Convalescence. There are but few writers on yellow 
fever who make any special mention of the character or the dura- 
tion of the convalescence from the disease. From their general 
silence upon this point, we might conclude that recovery is usu- 
ally speedy and entire. But Louis says, that in the Gibraltar 
epidemic of 1828, the convalescence, both in grave and mild 
cases, was long in proportion to the duration of the disease ; the 
strength of the patient, in severe cases, not being perfectly re- 

^ Du Typhus d'Amerique. Par Vr. Bally, p. 208, et seq. 

2 Amer. Journ. Med. Sci., Aug. 1833. 3 Ibid., Nov. 1834. 



492 YELLOW FEVER. 

established sooner than from ten to twenty days after the cessation 
of the febrile symptoms.^ Dr. Chisholm says, — "As long as the 
patient remained in the infected room or house, although all symp- 
toms of the disease had disappeared, the progress of recovery was 
remarkably slow;" but that a removal into the pure air was fol- 
lowed by rapid restoration to health.^ Arejula, in his description 
of the Cadiz epidemic of 1800, observes, that the debility and 
want of appetite following the disease always remained for some 
time, even after the fever had subsided.^ These statements are 
corroborated by some tables, published by Dr. Barrington, for the 
purpose of showing the difference in the duration of the disease 
depending upon it^ treatment. Of seven patients treated on the 
non-mercurial plan, two were fit for duty in eleven days, and the 
others in from twelve to twenty. Of seven treated by mercurials, 
one was fit for duty in twenty days, and the rest in from twenty- 
two to thirty-nine/ Deveze speaks of the convalescence as long 
and difficult, requiring all the aids of a good regimen.^ " Con- 
valescence," — says Bally, — "is a true malady, which on account 
of profound lesions, and the continuance of consecutive disorders, 
often leaves but feeble hopes; the senses remain more or less dull; 
the digestive organs are feeble ; and to these difficulties are fre- 
quently added, diarrhoea, cachexia, and marasmus."^ M. Catel, 
M. Chervin, M. Mongez, and others, speak of convalescence as 
nearly always prompt and complete. Dr. Lewis in speaking of 
the present epidemic of Mobile, — 1847, — remarkable for its harm- 
less and mild character, says that although the symptoms all 
subside on the fourth day, the patient is stripped of his strength, 
and can neither take exercise, nor sit up, for five or six days. 
Dr. Dickson says recovery is generally slow, and convalescence 
tedious and lingering." 

Convalescence is often accompanied by excessive activity of 
the sexual appetite. Deveze says he noticed this in both sexes 
at Philadelphia, and in St. Domingo. "Delicacy," — says Dr. 
Rush, — " forbids a detail of the scenes of debauchery, which were 

* Louis on Yellow Fever, p. 173. 2 Chisholm's Essay, vol. i. p. 406. 

2 Reports, etc., by Sir J. Fellowes, p. 53. ■* Amer. Journ. Med. Sci., Aug., 1S33. 

5 Traite de la Fievre Jaune, Par Jean Deveze, p. 33. 

6 Da Typhus d'Amerique. Par Vr. Bally, p. 272. 

7 Dickson's Essays, &c., vol. i. p. 352. 



RELAPSES.— SEQUELiE.— PERIOD OF INCUBATION. 493 

practiced near the hospital, in some of the tents which had been 
appropriated for convalescents." 

Sec. VI. — Relapses. Relapses seem to be rare; many writers 
do not mention them at all. Louis speaks of them as sometimes 
occurring, in cases where the disease had been violent, and brought 
on generally by errors of regimen. According to Dr. Gillkrest, 
however, they would seem to be more common. He says that 
there were one hundred and two cases amongst the soldiers at 
Gibrahar, in 1828.^ Arejula says, that at Cadiz, in 1800, re- 
lapses were very frequent and fatal. ^ Dr. Burnett quotes several 
writers who speak of the frequent occurrence of relapses. 

Sec. VII. — Sequclce. It does not appear that yellow fever often 
entails upon its subjects other and subsequent affections, either 
chronic or acute. A few writers, indeed, speak of chronic organic 
disorders, visceral ohstructions, as they w^re formerly called, as 
amongst the consequences of the disease, but in such loose and 
general terms as to deprive their remarks of all value. Dr. Bur- 
nett says, — ** The foundation of phthisis pulmonalis is often laid 
by this disease, and the patient, though saved from its immediate, 
is destroyed by its remote, effect.'" 

Sec. VIII. — Period of Incubation. The period of time w^hich 
elapses between the reception of the etiological poison of yellow 
fever into the system, and the formal access of the disease, seems 
to be generally limited to a few days. Occasionally, however, 
this period is somewhat prolonged. 

Dr. Luzenberg, of New^ Orleans, states that in the month of 
February, 1844, there were received into the Marine Hospital 
two sailors with yellow fever, w^ho had arrived from the West 
Indies, and who did not fall sick until they touched at the Balize, 
thirteen days after their departure. "^ 

' Cyc. Prac. Med., vol. ii. p. 280. 2 Reports, etc., by Sir J. Fellowes, p. 63. 

3 Burnett on Med. Fever, p. 12. 4 N. Q. Med. Journ., vol. i. p. 527. 



494 



CHAPTER YIL 

AlOETALITY AND PROGNOSIS. 

It must at once be seen, from the preceding history of yellow 
fever, that it is not an easy matter to determine the average rate 
of mortality from the disease. This rate varies very widely, in 
different seasons and localities, and with the different forms and 
grades of the disease. In some instances, it is excessive, — equal, 
perhaps, to that in the most malignant grade of puerperal fever. 
Dr. Gillkrest quotes Hurtado'^s Decadas, in which it is stated, that 
of the first one hundred and thirty-four cases treated at Murcia, 
in 1804, only three or four recovered ; he says, also, that in the 
early part of the epidemic at Gibraltar, in 1828, very few re- 
coveries took place in the Civil Hospital; and that of the first 
thirty-five Jews received into the establishment, all but one were 
swept away.-^ One of the deadliest epidemics on record is that 
of Mobile in 1819. Dr. Lewis informs us, that out of a popula- 
tion not exceeding one thousand, more than one half of whom 
were acclimated, there were four hundred and thirty deaths ' 
" The mulatto, the black, the Indian, and the white, the native 
and the stranger, — were alike its victims."^ Sir J. Fellowes esti- 
mates the population of Cadiz and its suburbs, in 1800, at 57,499. 
Official returns show that the number of persons attacked amounted 
to 48,520, of whom 7,387 died. The population of Seville, at the 
same time, was 80,568, out of which number 76,488 were attacked 
with the prevailing fever; the mortality amounted to 14,685; 
more than one-sixth of the entire population.^ Of eight hundred 
and thirty patients with yellow fever, received into the General 
Hospital at Barcelona, in 1821, seven hundred and forty-nine 
died. One thousand seven hundred and sixty-seven patient: 
were admitted into the Seminario Hospital; of whom, one thou- 
sand two hundred and ninety-three died."" 

1 Cvc. Prac. 3Ied.. voL iL p, 277. 2 X. 0. Med. Jour., vol. i. p. 2S5. 

» Reports, etc., by Sir J, Fellowes, p. 421. 
* 0"Halloran on Yellow Fever, pp. 97. 99. 



MORTALITY AND PROGNOSIS. 495 

At other times, and under other circumstances, the mortality is 
light. During the passage of the British store-ship Chichester 
from Jamaica to Halifax, in the months of October and Novem- 
ber, 1802, there occurred one hundred and forty-one cases of yel- 
low fever. Of the first, seventy-nine, only four recovered ; the 
remaining sixty-two all recovered! This enormous difference 
has been attributed to treatment; the first series having been 
treated by calomel, and the last by the lancet ; but when it is 
recollected that the ship was sailing north, and had reached the 
35th or 36th degree of latitude, when the mortality began to 
abate; and when it is added, that the weather at this time became 
very stormy, with lightning and rain, we can hardly hesitate in 
referring to these latter circumstances, at least the principal 
agency, in the production of the striking change which had taken 
place. ^ There are some facts mentioned by Dr. Lewis of Mobile, 
showing the differences in the severity of the disease, depending 
apparently upon the varying intensity of the poison, or the sus- 
ceptibility of the subjects, or both. The fever of 1819, he says, 
in Mobile, respected no character of persons ; the few whites, 
however, who survived, were acclimated. In the epidemic of 
1837, the old resident, if attacked at all, generally recovered; in 
1839, most of the citizens were attacked, — the long resident very 
mildly, and the stranger severely. In 1842, the disease was any- 
thing but epidemic, and confined to the lower part of the city. 
Every person brought to the hospital this autumn, with yellow 
fever, was unacclimated ; and the same thing was true of cases 
treated in private practice. Those which are called sporadic cases, 
occurring in healthy summers, are confined usually to persons who 
are strangers to the locality."^ In a private letter from Dr. Lewis, 
dated September 26Lh, 1847, speaking of the epidemic nowprevail- 
ing in Mobile, he says it is principally remarkable for its light 
and ephemeral character. He estimates that there have already 
been about five hundred cases ; less than forty of which have 
proved fatal; and nearly all of these occurred amongst strangers. 
Most of the cases have been amongst the acclimated. 

But independent of these difTerences, depending upon the vary- 
ing grades and character of the disease, there are certain circum- 
stances and conditions, influencing more or less the termination 

* Annual Register, 1802. 2 ^^ Q. Med. Jour., vol. i. p. 417. 



496 YELLOW FETER. 

of the disease, or indicating this termi nation. Amongst the 
symptoms which are looked upon as particiilaHy nn^Twable, are 
extreme restlessness, deep sighing, hiccoogh, suppression of 

urine, and especially black Tomit. This latter is regarded by 
o-eneral consent, as the precnrsor and harbinger, almost infallible, 
of death ; and such it most frequently is, but not always. Many 
extensive observers allege, that they have never seen a case of 
recovery, after the appearance of this symptom. Louis and 
Trousseau met with no such case at Gibraltar, in 1828. Dr. 
Rush makes a distinction between the true black vomit and the 
matter resembling coffee-grounds ; and he says that many pa- 
tients who discharged this latter recovered. Dr. Lewis, of Mobile, 
says, — " The recoveries after black vomit are exceedingly rare. 
I have ascertained, however, that fourteen patients were saved in 
1843, after the appearance of this usually fatal symptom. So 
long as the vomit is thick and pasty, being raised in small quan- 
tities and thrown up mixed with natural mucus, the physician 
€kjes not despair of his patient. The thin black fluid with the 
coffee-ground sediment is always, in Mobile, a fatal symptom. 
Four of the recoveries took place in the City Hospital, in charge 
of Dr. Ross ; the others were the patients of different medical 
gentlemen in private practice."^ Louis says, that recovery after 
black vomit occurs much more frequently amongst children than 
amongst adults.^ Hemorrhage, I believe, is generally regarded as 
an unfavorable indication. Dr. Chisholm says, he never found it 
critical, nor were the local pains ever permanently relieved by it. 
According to Dr. Lewis, hemorrhage from the gums and nose, 
taking place previous to the occurrence of black vomit, is favor- 
able ; and in females, hemorrhage from the uterus did not, in any 
case under his care, terminate fatally.^ Amongst the signs which 
Arejula considers as mortal, are the dark red or sub-livid color of 
the tongue, like that of a person after drinking red wine, with 
saliva sparing in quantity but viscid; darkness under the eyes; 
suppression of urine ; and a considerable irritation of the urethra, 
particularly towards the glans, forcing the patient to squeeze the 
penis, as happens to those laboring under a fit of the stone.* 

"■ N. O. Med. Joax, voL iL p. 300. 

• 'yit. Doughty sajs ke has seen manj hondEed eases of i^ack Tomi^ and nerer 
knew a patieat to sarviTe where &e m a tt y r ^. tibiown up finm die stooncb bad die 
appearance of coffee-groxmds. — Dotighty's Ofmrmiiam^ p. 14. 

» X. O. Med. Jour., toL L p. 300. ■* Bepoi^ rtc, I7 Sr J. FeOowes, p. 06. 



MORTALITY AND PROGNOSIS. 497 

Children, females, and negroes, as a general rule, have the dis- 
ease in a milder form, and of course with a smaller mortality, 
than other classes. The mortality at Gibraltar, in 1828, was one 
in four and a half, amongst the men; one in five and a half, 
amongst the women; and only one in seven, amongst children. 
But the mortality of these classes seems to be subject to variations, 
like those which mark most of the other features of the disease. 
Louis was assured at Gibraltar, by many medical men, who had 
witnessed several epidemics in that city, that the disease was 
sometimes much more severe in children than it was in 1828. 

The danger from this disease is said to be greatest in subjects 
whose habitual residence has been in countries most widely dif- 
ferent in their meteorological features from yellow fever regions. 
Bally says that in the Spanish epidemics, natives are less severely 
attacked than the French ; these latter less severely than Germans ; 
and Germans less severely than Swedes and Danes. 

The prognostics, as they are called, of the disease, are thus 
summed up, by Arejula. I quote from Sir James Fellowes' Re- 
port. *' The person attacked W'ith regular chills, a moderate pain 
of the head and loins, nausea and slight vomiting, pulse regular, 
and fever moderate, with a tolerable facility of moving himself, 
and who answ^ered questions put to him as clearly and as distinct- 
ly as usual, most commonly recovered; and his recovery was 
certain, if, after twenty-four or forty-eight hours, or even before, 
a gentle sweat broke out that lasted thirty hours or upwards, the 
pains subsiding with it, but without the pulse falling, or any of 
the animal or vital functions being apparantly disturbed. In 
general, those who were seized with the regular symptoms of the 
disorder, had a great advantage over those in whom the invasion 
came on w^ith irregular or anomalous signs. Those advanced in 
years were not in much danger, and a great proportion of old 
people escaped the disorder. Newly born infants and very young 
children were not so susceptible of the fever, and they got over it 
when attacked much better, comparatively, than those who had 
arrived at the age of puberty. Those of a white soft skin, and 
particularly of mild dispositions, escaped much better than per- 
sons of an opposite description. Females escaped better than 
males, but the fattest were in most danger. Females who were 

' Du Typhus d'Amerique. Par Vr Bally, p. 269. 

32 



wece nt 




B2^iy^ tfint tfiiis fispsr ssEardrasfi affl lis &is^w^am 

afii" 

« « -^ an; 

— CT> J. ^ (SB JP^ Ju 

fi^isiitiBi^vrdriif^it wasni^ftifljfafiiyia^^ lofts' it 
le i#tggg rfl» 







lie dlbaB^ ^ odnr of tfi^ 




€1^ As ^^fdSmiF l^gs&r of 

IIM^ 1M% Mil, aid ]^^ ^^- 



tftsiari 



, jIib£i' 



am- 



TBuTurtft nr» ^Mfl), 



MORTALITY AND PROGNOSIS. 499 

stitution suffer more than the feeble and delicate; but that this 
rule is not without qualification, — that violent epidemics, like that 
which prevailed amongst the French soldiers, at St. Domingo, in 
1802, and 1803, seize upon all alike, with very little distinction.^ 
He adds that in the torrid zone, death may be predicted with cer- 
tainty in a person who is seized with the disease amidst the lassi- 
tude occasioned by coition; and that in Spain the mortality 
amongst the newly married, and libertines, is greater than 
amongst others. 

' Du Typhus d'Amerique. Par Vr. Bally, p. 270. 



=00 



CHAPTER Yin. 

DIAGNOSIS. 

A sTB-O^GLT marked case of fatal or grave yellow fever can !: :.r :"~ 
be Gontbunded with any otiier disease. An imriatory clull of zi ; . t ■ 
rate duratioTi and severity, immediately foEowed by intense : ^ 
in tbe bead, back, and limbs: redness and sujfusion of the ijK^ , 
moderate excitement of tbe circulation ; moderate beat of the sur- 
face: loss of appetite; tbirst; and a wbite tongne, witb red tip 
and edo^es; these febrile symptoms, marking tbe first stage of tbr 
disease, contmoiii^ Ibr one day or so, and tben associated with. 
or followed by, epigastric pain and distress ; nausea aad voBiitnig : 
restlessness and anxiety, often more or less paroxysmal; and iz. 
firom three to five or six days, after tbe attack, by yellowness c: 
tbe eyes and skin ; vomiting o£ a laatter resembling cofiee gronnds 
held in a dark-colored fluid; ray daik ot black stools : ■:''■ 11^5'^ 
of tbe extremities; increasing aod ^Eceaave restlesszT:: ;_ 
occasional biccoagb; bemonbages from, different parts of uiz 
"body, and suppression of urine, — the mind in many instances 
remaining clear to tbe end, and death taking place in firom five 
to seven or eight days firom the attack : — tiiese phenomena, t&Bft 1 
combined and thus following each other, «»islitute a disease^ 
which it seems impossible to mistake for any other. 4.^iatigr cfeo- 
lera, puerperal peritonitis, and distinct smaH-poac aie out more 
clearly and broadly marked, by their pe-: :^:"r sml SauMtm^c 
phyaognomy, than the yellow fever, : :;;.ii: in iMs tern; and 
had we not abundant evidence of the extent to wbiA erw&i clear 
heads and sound juda:ment3 may be mystified and pcrr^ed by 
hypothctieal and a priori systems of medical plaiofiK^Iry, it would 
seem incredible that this disease should have been legnded, by 
many observers, as a variety merely of ordinary rentMest fever. 
A single remark should be made in relation to the state of the 
: : r : : : i " ; v . 7 :i t - : in tibe &^Maas of &tal : : : r : 

^^z :_- — z_ z-r.:: :;.__:_ :: :he disease are &e chanore \l :_: 



DIAGNOSIS. 501 

color of the liver, and the presence of the matter of black vomit 
in the stomach and intestines. In cases where either or both of 
these are found, we have an additional and very conclusive evi- 
dence of the nature of the disease. It is very important, how- 
ever, to add, that the absence of both these conditions is not to 
be taken as positive proof of the non-existence of the disease, 
in any given case, since it is quite certain, that in a considerable 
number of instances, death takes place without any formation of 
the matter of black vomit; and there is also good reason to be- 
lieve, that the change in the color of the liver is not a constant 
occurrence. 

The diagnosis of the more moderate grades of the disease, in- 
cluding even the severer forms which terminate in recovery, may 
be somewhat less positive, perhaps, than that of the foregoing 
cases; but it cannot often be attended with any difficulty, or 
doubt. It is very true, that some of the most striking features of 
the disease are often or usually wanting in these cases ; there is 
frequently no yellowness of the skin, but slight restlessness, and 
epigastric distress, or none ; and no black vomit ; but the violence 
of the local pains, the early suffusion of the eyes, and the rapidity 
with which the disease passes from the second stage to convales- 
cence and recovery, will be quite sufficient to supply their places, 
and to remove all uncertainty. 

The diagnosis of the milder and slighter form of yellow fever 
must often be more or less qualified and doubtful; and it will de- 
pend in part upon the circumstances under which the disease 
occurs. Thus, if a considerable number of persons in the same 
family, or neighborhood, are attacked, during the prevalence of 
yellow fever, with pains in the head, back and limbs, moderate 
febrile excitement and redness of the eyes, — especially if these 
persons are mostly children, negroes, or individuals more or less 
acclimated, there can be but little doubt, if any, in regard to the 
character of the disease. Mr. Pym says, — "The most character- 
istic symptom of the disease is the peculiar pain in the forehead 
and eye-halls^ with the drunken appearance of the eye."^ 

Again, the diagnosis may sometimes be rendered somewhat 
doubtful, by the presence of the remittent or periodical element 
in the disease. Dr. Lewis, of Mobile, has called the attention of 

' Burnett, p. 209. 



502 YELLOW FEVER. 

physicians particularly to these mixed cases, and to the difficulty 
which often attends their diagnosis. It does not appear, however, 
that the peculiar features of yellow fever are much modified, or 
the usual course of the disease much interfered with, by the ad- 
dition of this periodical or remittent character. Dr. Lewis, in his 
description of the Mobile epidemic of 1843, says, — "Some phy- 
sicians complained, that they were always taken by surprise in 
these cases; that there was no symptom which could lead them 
to suppose, that they were cases of yellow fever; hence they 
viewed them as simple intermittent, running, under atmospheric 
influence, into black vomit. I was deceived in three cases only; 
two of which were under my treatment, and the other I saw by 
accident. After this, I was able to make a proper diagnosis, 
usually on the second or third day. During the apyrexia, there 
were the peculiar pulse and uneasiness belonging to the calm or 
passive stage of yellow fever; and in the absence of these, the 
eye or skin was sometimes indicative of the character of the dis- 
ease."^ 

Finally, cases will unquestionably now and then occur, so in- 
distinctly and obscurely marked, or so mixed up with other mor- 
bid phenomena, — so anomalous and irregular in their symptoma- 
logical manifestations, — as to escape the scrutiny of the closest 
and most experienced watcher. What is true of most other dis- 
eases is true also of this ; and here as elsewhere, in the domain 
of diagnosis, although as a general rule, and in an immense ma- 
jority of cases, our conclusions may be absolute and positive, we 
are sometimes held to the necessity of being satisfied with such as 
are only qualified and approximative. 

^ N. 0. Med. Jour., vol. i. p. 292. 



1 



503 



CHAPTER IX. 

THEORY. 

The theory of yellow fever, like that of the preceding diseases, 
can consist at present, only of a few probable approximations. 
We may pretty safely say, in the first place, that it is not a sim 
pie gastritis. Notwithstanding the general presence, and the 
grave character, of the lesions of the gastric mucous surface, in 
fatal cases ; and the corresponding constancy and gravity of the 
gastric symptoms, it seems to me, that a rational interpretation 
of all the phenomena of the disease leads inevitably to the conclu- 
sion above stated. The order of succession, in the phenomena 
of yellow fever, is not such as occurs in simple acute gastritis. 
The gastric symptoms do not accompany the general febrile ex- 
citement; the latter precedes the former. li^the high fever of the 
first period is dependent upon gastritis, there should be, at the 
same time, some local symptoms of this latter. The first stage 
of the disease is not accompanied by any signs of gastric inflam- 
mation ; and in mild cases, and not unfrequently, also, even in 
pretty severe cases, which terminate in recovery, there are no 
such signs during any period of the disease. This could not be 
so generally the case, if the disease consists primarily and essen- 
tially in an inflammation of the mucous membrane of the stomach. 
The gastritis, there is every reason to believe, is a secondary lesion, 
like that of Peyer's glands in typhoid fever, one of the results, 
immediate or remote, of the unknown poison of the disease. 
This interpretation is in no way inconsistent with the importance 
which I am disposed to attach to the local disease. This is proba- 
bly one of the principal causes of danger and death. 

Of the peculiar lesion of the liver, I have already sufficiently 
spoken. We know too little of its nature and relations, to justify 
us in attempting to estimate its importance, or to fix its position, 
in the theory of the disease to which it belongs. 

It is very probable that a most important element in the patho- 



505 



CHAPTER X. 

TREATMENT. 

Sec. I — Prelimiimry. The treatment of yellow fever is not yet 
settled. The conflicting opinions, which we have so often en- 
countered in the course of our previous investigations, again meet 
us here. I do not mean to say, that there are not now, or that 
there have not always been, individual practitioners, thoroughly 
believing, and confidently proclaiming, that they themselves had 
ascertained the best and most effectual means of combating and 
controlling this disease, — of diminishing its severity, and prevent- 
ing its fatal issue. There are now, and there always have been, 
multitudes of such. It is indeed a very remarkable fact, that in 
no department of practical medicine have loftier pretensions been 
made, than in this; nowhere else, has there been claimed a more 
entire and absolute control over disease, than here. Medical 
skill has plumed itself upon its most brilliant successes; medical 
art has proclaimed its most wonderful power, in the treatment 
of yellow fever. Dr. Rush said, that during the great Philadel- 
phia epidemic of 1793, at no time did he fairly lose more than 
one in twenty of his patients; and a like siren accompaniment 
runs through the long and stormy annals of the disease. But still 
yellow fever has lost none of its ancient terrors; the blow with 
which it strikes down its victim, to-day, in New Orleans, is as 
unerring and resistless as it was half a century ago at Cadiz or 
Gibraltar. Neither is there any general agreement amongst medi- 
cal men, in regard to the most effectual means for controlling the 
disease; one method is recommended by one observer, another 
by a second, and another by a third. These are the grounds for 
the statement with which I have commenced this chapter, — that 
the treatment of yellow fever is not yet settled. 

Under such circumstances, the duties of a conscientious his- 
torian of the disease, although they may be difficult, are suffi- 
ciently plain. He is not to dogmatize; and he is to be especially 



506 YELLOW FEVER. 

careful not to espouse opinions of an exclusive, partisan, and 
doubtful character. His functions are those of the judge, and not 
those of the advocate ; he is carefully to examine and analyze the 
evidence before him, and honestly to estimate its value: and then 
as nearly and as fully as his means and ability will enable him, 
he is to state the case as it is, — clearly and fairly, without preju- 
dice and without passion. 

In the further prosecution of this subject, I shall first speak of 
the three remedies which have attracted most attention, and which 
have been most extensively used, — I mean, mercurials; bleeding; 
and tonics, or stimulants; and I shall then mention some other 
methods of treatment that have been adopted by certain practi- 
tioners. 

Sec. II. — Mercurials. By the mercurial treatment of yellow 
fever, I mean the use of mercury for the purpose of producing its 
specific effects on the system, as indicated by the presence of 
salivation. This practice constituted the favorite method of many 
British, and of some few American, physicians ; and it has been 
long and very extensively applied. One of its earliest and most 
zealous champions was Dr. Chisholm. He placed his sole reli- 
ance upon it for the cure of the disease. His usual mode of ad- 
ministering it w^as to give ten grains of calomel, either alone, or 
in combination w^th jalap, at the beginning of the disease, and 
then to repeat the calomel, either alone, or in combination with 
opium, every three hours, until the salivary glands became 
affected ; which generally happened, he says, in less than twenty- 
four hours from the commencement of the treatment. Dr. Chis- 
holm speaks of this treatment as new; says that he resorted to it, 
not on the authority of others, but led by his own reflections on 
the nature of the disease, and by the ineffxcacy of the means 
which he had already made use of; and he always speaks of his 
success as astonishing as it was gratifying.' Dr. Gillkrest enu- 

• In a subsequent part of his work, Dr. Chisholm justifies his free use of mer- 
cury, by showing that the practice was not new in the treatment of the West India 
yellow fever; but that it had been extensively adopted near the middle of the then 
century. Dr. Bancroft quotes Dr. Henry Warren, as saying, in 1740, after alluding 
to what he calls a very odd and unwarrantable practice which had prevailed for 
many years among several of the plantation practitioners of Barbadoes, of giving 
calomel in inflammatory fevers, that he had never yet heard of mercury being given 
in this malady and hoped he never should hear of it. — Bancroft's Essay, p. 77. 



TREATMENT.— MERCURIALS. 507 

merates a great number of British practitioners who still rely upon 
this method ; and he gives to it the sanction of his own experience. 
Amongst American physicians of the present day, who adopt a 
similar practice, the most distinguished is Professor Dickson, now 
of the New York University, and late of Charleston, S. C. Dr. 
Dickson has been long familiar with yellow fever, and he gives 
his most emphatic and unqualified testimony to the excellence 
and superiority of this method. Still, it can hardly be denied, 
that the balance of authority is on the other side of this question. 
Nearly all the French and Spanish, most of the American, and 
many of the British physicians, now doubt the value of this mode 
of treatment; or they are decidedly opposed to it. Dr. Burnett 
says, — "I have heard of the utility attending the exhibition of 
mercury in this disease ; but I can with truth affirm, that employed 
in any other shape than as a purgative, I have never seen it in 
the early stage attended with the smallest advantage." He 
sailed, he says, for Jamaica, in 1802, strongly prepossessed in 
favor of mercury, but a service of nearly a year and a half on that 
station served to convince him that he had greatly over-rated its 
virtues. Without particular reference to the many patients who 
perished around him, in the ships, and the hospitals, four of his 
most intimate friends died under the use of mercury, one of them 
fully salivated. In protracted cases, with signs of cerebral dis- 
ease, he thinks it of great service, in small doses. 

Mr. Doughty says, — "In our hospital, which I have stated, 
w^as soon crowded, and with cases of the most aggravated nature, 
the mercurial plan of treatment was for a time tried, but with no 
success, as in seven cases out of ten the mouth could not be 
affected; where the mercurial action did manifest itself, the pa- 
tient was considered safe ; but this effect was so uncertain, that I 
shall never be led to adopt it again, as a general plan, should 
any circumstance induce me to revisit the West Indies." 

Sir James Fellowes, in a notice of the epidemic at Cadiz in 
1813, says, — " Mr. Short, the surgeon of the German battalion, 
informed me, that five soldiers were taken ill whilst under a state 
of ptyalism, from the use of mercury. They all recovered. Mer- 
cury, in the hands of Staff-Surgeon Vance, proved to be of no 
use, except as a purgative in the beginning of the disease."^ 

^ Reports, etc., by Sir J. Fellowes, p. 300. 



508 YELLOW FEVER. 

Dr. Bancroft says, — "I cannot, with an eminent and respecta- 
ble physician. Dr. Grant, who treats of this practice, aver, that 
although I have been called in to attend many under such cir- 
cumstances, not one survived, and that they became more victims 
to the mercury than even to the fever ; but I can aver, that I had 
not a few opportunities of observing the effects of mercury given 
in this disease, while I served, in 1796, and 1797, as physician 
to the army, under Sir Ralph Abercrombie, in the West Indies: 
and that I saw nothing, which, to my understanding, could afford 
a proper encouragement to continue the mercurial practice ; and 
therefore though I have adopted no invincible, nor, as I hope, 
unreasonable, prejudice on the subject, I cannot venture to re- 
commend the use of mercury to excite salivation in yellow fever, 
without further evidence of its utility."^ Louis says there was no 
reason to think that the mercurial practice was of any utility in 
the yellow fever of 1828, at Gibraltar. 

Sec. III. — Antiphlogistic Method. Early and free general 
blood-letting, with or without the local abstraction of blood from 
the head, or epigastrium, or both, has constituted a common and 
favorite mode of treatment with many practitioners. Our distin- 
guished countryman. Dr. Rush, it is well known, was one of the 
staunchest champions of the lancet in yellow fever. He stood by 
it, through evil and through good report, with a tenacity and deter- 
mination, characteristic of the polemics of our profession. In his 
account of the fever of 1794, in Philadelphia, he gives a tabular 
statement of his bleedings, in twenty-three cases. The number 
of bleedings, in each case, varied from three to fifteen ; in more 
than half the cases, he bled nine times, or more ! The quantity 
of blood taken from each patient varied from fifty to one hundred 
and fifty ounces, — the average quantity being ninety-three and a 
half ounces!^ In 1797, Dr. Dewees is said to have bled Dr. 
Physick, in yellow fever, to the extent of one hundred and seventy- 
six ounces.^ One of the boldest bleeders w^as Dr. Robert Jack- 
son, the Englishman, in his practice in the West Indies. His 
common quantity was from three to six pints, taken suddenly, and 
at once. His treatment was founded on a pnori notions, and has 
nothing but general assertions to justify it. Dr. William Burnett, 

» Bancroft's Essay, p. 85. 2 Med. Inq., vol.iii. p. 221. a Ibid., vol. iv. p. 22. 



TREATMENT.— ANTIPHLOGISTIC METHOD. 509 

who was at the head of the Medical Department of the British 
Navy in the Mediterranean, from 1810, to 1813, regarded yellow 
fever in its early stages as purely inflammatory. The disease, he 
says, is then simple in its nature, and easily to be managed ; and 
the fate of the patient is in the hands of the physician. He relied 
principally on blood-letting, general and local. He says, that 
although syncope is often occasioned by the loss of a few ounces 
of blood, the bleeding should be repeated if it is not specially 
contra-indicated, — the patient being placed in a horizontal posi- 
tion. He lays great stress on the value of bleeding from the tem- 
poral artery ; he says the headache is greatly ameliorated, if not 
entirely removed, by this operation, and that in many instances 
the patients feel the pain escaping with the blood. In one case, 
he bled from the temporal artery to the amount of ninety ounces. 
In many instances, he bled to the amount of one hundred and 
thirty, one hundred and forty, and even two hundred ounces.^ 

An interesting, and, as far as it goes, a very conclusive, trial of 
the comparative merits of the antiphlogistic and mercurial methods 
of treatment, was made during the years 1828, 1829, and 1830, 
on board some of the United States vessels, in the neighborhood 
of the West Indies, and in the hospital at Pensacola. On board 
the Hornet, there were fifty-five cases, and eight deaths. The first 
twenty-six were treated on the mercurial plan ; and five of them 
were fatal : — the remaining twenty-nine were treated on a differ- 
ent plan; and three of them were fatal. Of the few w^ho were 
bled, every one recovered. In the Grampus, there were thirty-six 
cases, and four deaths. The treatment, generally, was pretty 
actively antiphlogistic. There was no death after venesection. 
From the Peacock, there were sent to the hospital, at Pensacola, 
thirty-eight patients, nine of whom died. The treatment in the 
hospital was mercurial ; but on board ship it was antiphlogistic. 
Of the nine fatal cases, eight were treated with mercury, of whom 
five were salivated, or had the mouth aflfected. The average du- 
ration of the disease, including convalescence, was about one week 
greater in those treated by the mercurial, than in those treated by 
the non-mercurial method.^ 

I could add largely to these testimonials in favor of the value 
of blood-letting. It is true, nevertheless, that the practice is very 

' Burnett on Med. Fever, p. 19, 2 Am. Jour. Med. Sci., Aug. 1833. 



510 -VELLOW FEVER. 

far from being generally adopted, and it has always encountered 
very strong and decided opposition. This bold depleting prac- 
tice has failed to commend itself to the general favor of the pro- 
fession ; we may go further than this, and say that it is generally 
rejected as improper and unsafe. Dr. Chisholm says, that in 
young and robust subjects, newly arrived, and with strongly 
marked inflammatory symptoms, one plentiful bleeding may be 
of infinite service ; but, as a general practice, he condemns it in 
the strongest and most unqualified terms. Not a single case, 
he says, in which bleeding has been employed as a principal 
remedy, has terminated favorably. Sir James Fellowes says, — 
"As far as my information extends, the practice of bleeding has 
been of late entirely laid aside in Spain in the treatment of this 
fever; and although I have seen some patients recover in the few 
instances in which it had been followed, it did not appear to be 
necessary or proper."^ Sir Gilbert Blane says, — "With regard 
to blood-letting, the most that can be said in its favor is, that, if 
there should be a hard, throbbing pulse, with violent pain in the 
head and back, it is safe^ in the first twelve hours. It is, however, 
in all cases extremely dangerous, except in the circumstances just 
mentioned."^ The leading practitioners of Mobile reject it almost 
entirely. Dr. Dickson does the same. 

As a means of reducing the active excitement of the first stage, 
and as a substitute, in some degree, for blood-letting, the cold 
affusion has been made use of. Dr. Dickson praises it very highly. 
" Relief from the pungent heat of the skin," — he says, — " the tor- 
menting thirst, the distressing headache, the pain and irritability 
of stomach, you will never fail to procure. This relief, it is true, 
will be partial and transient, but the remedy may be repeated as 
often as seems requisite, without danger or injury. The termina- 
tion of the chill, if there be one, when the face becomes flushed, 
and the surface dry and hot, a condition almost characteristic in 
the degree attending this form of fever, is the moment for affusion. 
Seat your patient in a convenient vessel, and pour rapidly from 
some slight elevation, upon his head and shoulders, and over his 
naked body, a full large stream of cold water, continuing it until 
his face becomes pale, or his pulse sinks. In general, the sick 
man himself will exult in the delightful ease which follows it, and 

• Reports, etc., by Sir J. Fellowes, p. 407. 2 Obs. Dis. Seamen, p. 414. 



TREATMENT.— TONICS.— PURGATIVES.— SPANISH METHOD. 511 

will solicit its frequent repetition. I have never yet seen any un- 
pleasant consequences from it. Even children and timid women 
reconcile themselves readily to the shock of the affusion, and regard 
it as pleasurable rather than otherwise. The surface should be 
rubbed dry, and the patient, on lying down, covered so as to be 
comfortably warm." 

Sec. IV. — Cinchona; Tonics and Stimulants. There have 
always been a certain number of practitioners, who have pursued 
a decidedly tonic and stimulating course in the management of 
yellow fever, even from the commencement of the disease. Dr. 
Lafuente, a Spaniard, was in the habit of giving six or eight 
ounces of Peruvian bark during the first forty-eight hours of the 
disease ; and this practice, with certain modifications, still finds 
some advocates and disciples. I do not think there is any satis- 
factory evidence of its efficacy ; although it is very possible that 
it may be useful in those cases of the disease which are compli- 
cated with the pathological element of periodicity. I am not now 
speaking of the use of cordials and stimulants during the second 
and third stages of the disease. These remedies are very gene- 
rally resorted to at this period. 

Sec. V. — Purgatives. There is a pretty uniform agreement 
amongst practitioners in regard to the propriety and advantages of 
an early and efficient cathartic in the treatment of yellow fever. 
Different articles are used by different physicians ; as a general 
rule, Spanish and French practitioners preferring the milder and 
blander laxatives, while British and American physicians usually 
resort to calomel in combination with, or followed by, some other 
purgative. Dr. Rush's famous powders of calomel and jalap, are 
well known. Dr. Dickson promotes the action of the calomel by 
the use of epsom salts. 

Sec. VI. — Spanish Method. Yellow fever prevails nowhere 
more extensively, than along the Mediterranean coasts of Spain; 
and it can hardly fail to be of some interest to my readers to know 
the plan of treatment generally adopted by the Spanish physi- 
cians. This plan, with the exception of the ultra bark treatment 

* Dickson's Essays, &c., vol. i. p. 360. 



512 YELLOW FEVER. 

of Fuente, is pretty uniform ; and consists principally, in the use 
of mild and cooling laxatives, such as supertartrate of potass and 
tamarind water, with subacid drinks, in the early stages of the 
disease, and cinchona in the latter period. There is a general 
aversion, amongst the Spanish practitioners, to the lancet and 
mercury. Dr. Flores, at Cadiz, in 1813, at his first visit, which 
was usually in the evening or night, ordered an injection of sweet 
oil, warm aromatic drinks, and sinapisms to the feet. The next 
morning, he gave ten grains each of calomel and jalap, with bar- 
ley water, or light broth, promoting their action, if necessary, by 
enemata. If vomiting was present, the calomel was given in 
divided doses, in pills, and continued till it operated on the bow- 
els. Its free action was generally followed by relief, — general 
tranquillity, mitigation of local pains, and perspiration. On the 
approach of the third stage, tincture of cinchona, animal broths, 
sago and wine, were resorted to. If there were threatenings 
of black vomit, a vinegar and mustard poultice was applied 
to the epigastrium, saline injections were administered, and sweet 
spirits of nitre and opium were added to the bark and cordials. 
The practice of Sir James Fellowes was much the same. 

Sec. VII. — Mobile Method. According to Dr. P. H. Lewis, 
the physicians of Mobile have, with great unanimity, adopted a 
method of treatment, corresponding pretty nearly to the foregoing. 
He speaks especially of the severe and malignant forms of the 
disease, — milder cases generally recovering under various and 
even opposite systems of management. In the early stage, they 
give a dose of calomel, followed by castor or olive oil, or salts 
and senna, so as to act freely upon the bowels. If the rigors 
continue long, a warm mustard bath is ordered. Perspiration is 
promoted by warm drinks ; and cups are applied to the cervical 
or epigastric region, as they seem to be indicated. In the second, 
or stage of calm, no active system of practice is pursued. The 
lighter diffusible stimulants and diaphoretics are usually given 
with blue pill. The transition of the disease from the second to 
the third stage is carefully watched, and met with an active stimu- 
lating treatment. Brandy toddy or julep is usually preferred. 
It is cautiously given, until it is ascertained that the patient 
has a relish for it ; after which it is pressed until the depressing 
tendency of the disease is fully arrested. After the restlessness 



TREATMENT.— PROPHYLACTICS. 513 

has moderated, and the pulse rallied, the stimuli are continued in 
such quantities as are necessary to sustain the patient. After the 
liberal use of brandy, small quantities of chicken or oyster broth 
are cautiously given ; if this should also be retained by the sto- 
mach, the fears of the approach of black vomit, which were pre- 
viously entertained, begin to fade away. General bleeding, in 
this class of cases, is considered improper and hurtful. It is re- 
sorted to only in the febrile stage of the open inflammatory form 
of the disease, and is even then used cautiously. But small re- 
liance is placed upon quinine. *' No physician in Mobile, who 
has any experience, expects to cut short a grave and serious case 
of yellow fever." My readers can hardly fail to be struck with 
the almost exact similarity between the Spanish and the Mobile 
methods of treatment. 

Dr. Nott of Mobile has for several years been in the habit of 
administering creosote during the febrile stage. After opening 
the bowels, he puts twenty drops of creosote to six ounces of 
spirit of Mindererus, with alcohol enough to dissolve the creosote ; 
and then gives half an ounce every two hours. Dr. Lewis says 
of this remedy; — " It is certainly the most efficacious means for 
arresting the disposition to vomit and retch that I have yet found." 

Sec. VIII. — Prophylactics. There can be no doubt, I sup- 
pose, that the most effectual means of warding off the disease 
from those who have been exposed to its essential cause, are to 
be found in cleanliness, temperance, and cheerfulness. The two 
former conditions it is not difficult to comply with ; but according 
to what code of metaphysics or philosophy, the solemm w^arnings 
to men, standing in the very shadow of the wings of the angel of 
pestilence, to be of good heart, and not afraid, — and this too at 
the peril of their lives, — are expected to be heeded, is more than I 
am able to understand. In connection w^ith the prevention of the 
disease on ship-board. Dr. Barrington says, — " The chloride of 
lime is an important agent in purifying places inaccessible by the 
scrubbing-brush and holy-stone, and destroying the noxious efflu- 
via of crowded apartments. That it is highly useful on ship- 
board has been sufficiently demonstrated. It is now in general 
use in the West India squadron. In the late cruise of the Erie 
this article was dealt out unsparingly, and occasionally to the 
temporary annoyance of those on board ; and I am convinced that 
33 



514 YELLOW FEVER. 

to this, with the prompt and effective cooperation of the executive 
officer, in having every tangible part kept free from fihh, may be 
chiefly attribute that ship's escape from the most alarming 
disease of the tropics. The chloride mixed with water was 
poured into the pump-wells, and distributed throughout the holds, 
chain-lockers, berth deck, and other parts." "Music," — con- 
tinues the same sensible writer, — " though not often regarded as 
a preventive, is in my opinion an important mean of placing the 
system, through the influence of the common sensorium, in a 
favorable condition to resist the action of the morbific causes. 
Smoking tobacco must also be enumerated amongst the means of 
keeping off attacks of fever in what are called miasmatic situa- 
tions. In an infected atmosphere, particularly at night, I have 
seen and experienced sufficient not to doubt its utility."^ 

Sec. IX. — Conclusion. I shall finish this chapter with the fol- 
lowing conclusions, which we are justified, I think, in adopting. 

The simple and milder form of yellow fever, occurring some- 
times in unacclimated adults, but more frequently amongst the ac- 
climated or partially acclimated, and in children, usually terminates 
favorably, independent of any of the ordinary modes of treatment. 
Perhaps this termination is promoted by a mild but efficient cathar- 
tic. 

The open inflammatory form of the disease is mitigated in se- 
verity, and its danger diminished, by proinpt and pretty free blood- 
letting, — general and local; and by an efficient cathartic. 

The congestive form of the disease, and the other forms, if they 
pass into the stage of collapse, usually terminate fatally, and are 
but little under the control of art. In these cases, the method of 
treatment usually followed by Spanish practitioners, and adopted 
by the physicians of Mobile, seems to promise more success than 
any other. 

Finally, and lest some of my friends may think me over cau- 
tious in ray conclusions, I shall add to what I have said the seal 
of hoary wisdom, and the sanction of ripe knowledge. Lempriere 
says, — "I am very apprehensive, from experience, that both 
parties have been too sanguine in their practice, and that many 
of the successful cases have been confounded with the common 

* Amer. Jour. Med. Sci, Aug. 1833. 



TREATMENT.— CONCLUSION. 515 

remittent ; and that as yet we have not ascertained what is the 
most judicious mode of treating the disease ; and I am likewise 
convinced, that there are many cases which from the first attack 
are fatal, and which from their nature, totally exclude the chance 
of recovery by medicine."^ 

Let us listen to the great Sir Gilbert Blane; — he says, *^I feel 
this as the most painful and discouraging part of this work, the 
yellow fever being one of the most fatal diseases to which the 
human body is subject, and in which human art is the most un- 
availing. 

"It seems hardly to admit of a doubt that there are particular 
instances of disease, in their own nature, determinedly fatal ; that 
is, in which the animal functions are from the beginning so de- 
ranged, that there are no possible means in nature capable of 
controlling that series of morbid motions which lead to dissolution. 
Of this kind appear to be the greatest number of cases of the 
plague, many of the malignant small-pox, and some of fevers, 
particularly of that kind now under consideration."^ 

1 Obs. Dis. Army. Lempriere, vol. ii. p. 92. 2 Qbs. Dis. Seamen, p. 411. 



516 



CHAPTER XL 

DEFINITION. 

Yellow fever is an acute affection ; occurring at all ages, but 
much more frequently during the middle and active period of 
life, than either earlier or later; attacking, in a large majority of 
instances, persons who are not permanent residents in the places 
Vhere it prevails, — sometimes extending, however, especially in 
localities where it is of rare occurrence, to such residents; rarely 
occurring twice in the same person; much more common in the 
white than the negro race; generally milder in its character 
amongst children and women than amongst men; confined to 
certain geographical localities, and especially to commercial sea- 
ports in hot climates ; prevailing most extensively during the latter 
part of the hot season; often epidemic, but sometimes sporadic 
in its appearance; not capable of transmission from one person 
to another in a pure atmosphere; depending, for its essential 
cause, upon a poison, of terrestrial origin, the nature and com- 
position of which are entirely unknown, — which poison may be 
shut up in small and close apartments, in clothes, bedding, and 
so on, and transported from one place to another, and which is 
destroyed by a freezing temperature: — sudden in its access; 
commencing with an initiatory chill, ordinarily of moderate se- 
verity, and of short duration; the latter accompanied with acute 
and violent pains in the head, back, and hmbs, or immediately 
followed by them; then by a red suffusion of the eyes, moderate 
heat of the skin, and moderate acceleration of the pulse, loss 
of appetite, and thirst; a moist, white, villous tongue, with rosy 
tip and edges; — these febrile phenomena diminishing in activity, 
and mostly disappearing, in from twenty to thirty-six hours; — 
the first stage of the disease, thus characterized, passing, in mild 
cases, into convalescence, but in grave cases being followed, 
after an interval of apparent but deceptive amelioration, by nau- 
sea and vomiting, — the matter ejected from the stomach, in cases 



DEFINITION. 517 

that are to terminate fatally, resembling coffee-grounds ; black or 
dark- colored stools; epigastric distress, general restlessness, and 
jactitation; sighing respiration; hiccough; a yellow color of the 
skin; coldness of the extremities gradually extending to the 
trunk; and, finally, by death; — the mind usually remaining free, 
but apathetic and indifferent, up to the close of life ; which symp- 
toms differ very widely in their degree of severity, and especially 
in their number and combination, in different cases, thus giving 
rise to different varieties and grades of the disease ; which symp- 
toms, furthermore, may either subside and disappear, in the 
course of a few days from the time of their commencement, or 
may terminate with death, between the third and seventh day of 
the disease ; the bodies of patients exhibiting, on examination 
after death, in most cases, a yellow or buff color of the liver, 
with dryness of its tissue ; black spots or masses, more or less 
numerous, in the lungs ; softness and flabbiness of the substance 
of the heart; and in nearly all cases, unusual thinness and 
fluidity of the blood ; and redness, mamellonation, changes in the 
thickness, and softening — one or more — of the mucous membrane 
of the stomach ; this organ and the intestines usually containing 
a considerable quantity of a very dark or black fluid or semi-fluid 
matter; which disease differs essentially from all others, in its 
causes, its symptoms, and its lesions ; and is only to a moderate 
extent, at least in its graver forms, under the control of art. 



51S 



CHAPTER XIL 

BmnOGKAFHT. 

Mr readers wiH not expect me co artempc to embrace in a sliort 
sapplementary cliapter like this the almost honndless dom.aiii of 
the literature of yeUow fever. I shall content myself with, doing 
Iiere wtat I haTe done in tke corresponding portions of tlie pre- 
ceding parts of my book ; — I stall enumerate merely some few of 
tJie pablications upon yellQw fever^ confining myself mostly to 
ttose of original pretensions, and from whicL. tke materials &r tlie 
feregoing history have been mainly deriTed. It is proper that I 
should here express my acknowledgments to Dr. La Roche for 
the free use which he has giyen me of his very elegant and com- 
plete library of this disease* 

O^ervaiians on the Dis&iaa imddent to Seajnen. By Gilbert 
Bi(me,M,I)., F.KS,, etc, Limdan, 1TS5. Sfr GEbert Blane 
was surgeon to the great British fleet, under Admiral Rodney, and 
Lord Hood, during the French, Spanish, and American war, from 
1779 to 17S3. The fleet consisted of from twenty to forty ships 
ef &e line, — the whole force sometimes amounting to more than 
twenty thousand men. The principal theatre of its operations 
was the neighborh'--"-: -"' ~h.e West T" r> I:^.^.-::5. although por- 
tions of the fleet ~ - t .iionally " : . : ^ id fro, between 
the Islands, and Norm America and Grear Bntain. Sir Gilbert 
Blane^s volume, of five hiisii££fi page% is mfistly Hiade up of a 
medical history of the ^eet, wad. of ii'iiuiiifr tzeadses on what he 
r-r,!: "i three sm tfmkamss^^-fenF^ mvt^ amd ^gmakrij 
TIi^j Tiri, like all tfee wiftnigs (£ Mane, is marked, tiiro«gfeor.~. 
hy sound common sense, accurate observation, clear-head ei 
sagacity, and the most thoroughly positive and correct medical 
|ihiIosophy. It is deplorable that this philosophy is so rarel" 
fimnd in the works of his countrymen. Some notion of the exten: 
of Blane^s experience, as weO. as of the terrible destructiveness 
of the service to wiiich he was attached, may be gained from the 



BIBLIOGRAPHY.— HILLARY.— MOSELY. 519 

statement, that in the period of three years and three months^ the 
number of deaths, in the fleet and hospitals, amounted to four 
thousand three hundred and forty-eight ; of this number, three 
thousand and two hundred perished from disease. Upwards of three 
thousand were also lost at sea, in the hurricane of October, 1780, 
and in the storm of September, 1782. The descriptions of yellow 
fever, and of bilious remittent fever, are short, but clearly, accu- 
rately, and excellently written; and many of his observations 
have been incorporated into my book. 

Dr. William Hillary''s Observations^ on the Weather and the 
Diseases of the Isla?id of Barhadocs, is a most excellent and sen- 
sible book. His description of yellow fever is wonderfully graphic 
and true. He thought the disease was not contagious, except, 
perhaps, in some rare cases. His treatment consisted in early, 
moderate bleeding, followed by mild purges, diluent drinks, and 
in the latter periods, by stimuli and cordials. ** This method,'' 
— he says, — "has been, and may probably be thought by some 
others, too simple and easy, to conquer so violent and formidable 
a disease. What! only bleed once or twice, and give a little 
warm water, and two or three simple purges, and this simple 
julep, to subdue such a terrible disease! without any fine boluses, 
cordial volatiles, and vesicatories! But I must tell such persons 
that the more simple the method is, if it be but judiciously and 
fitly adapted to the nature and cause of the disease, it is so much 
the better."^ One hardly knows what to make of his statement 
that in a practice of eight years he had seen only two patients, 
treated in this manner, die! The American edition contains no 
clue to the period of time during which the observations were 
made, but as an offset to this and all other omissions, it is well 
barnacled over with notes by its illustrious editor. 

A Treatise on Tropical Diseases, etc. By Benjamin Mosely, 
M. D. London. Dr. Mosely's work was first published in 1787; 
thus preceding, by several years, the great epidemic period of yel- 
low fever which commenced in 1793. It is quite miscellaneous 
in its contents; — containing remarks on military operations in the 
West Indies; on dysentery; on the endemial causus, as he calls 
it, or yellow fever; on tetanus, and other diseases; and, finally, 
on. the influence of the moon. I know nothing of the personal 

' Rush's Hillary, p. 125. 



520 YELLOW FEVER. 

history or character of Dr. Mosely ; but his book, — notwithstand- 
ing its faults, — its lumber of learning, its parade of ancient error 
and credulity, and its want of method, — is one of the raciest, 
freshest, and most entertaining, in medical literature. Dr. Mosely 
expresses his disbelief in the contagiousness of all forms of pesti- 
lential fever. He looks upon yellow fever as totally different from 
the bilious remittent. His description of the disease is short, but 
exceedingly vivid and striking. His treatment was by free and 
repeated bleeding, at the commencement, followed by the warm 
bath, and saline purges, diaphoretics, and large quantities of cin- 
chona. In the second stage, he insists upon the necessity of still 
further purging. 

Observations on the Diseases of the Army in Jamaica^ etc. By 
John Hunter, Jif. D., F. R. S., etc. London, 1788 : pp. 315. John 
Hunter had the care of the British Military Hospitals in the island 
of Jamaica, from 1781, to 1783 ; and this little book contains the 
results of his medical experience, during this period of time. Like 
the greater labors of Mr. Hunter, this lesser w-ork is marked 
throughout by close observation and sound sense ; although it adds 
but little to our knowledge of yellow fever. He did not regard 
the disease as essentially different from bilious fever ; and he saw 
no evidences of its transmissibility by contagion. 

Practical Observations on the Diseases of the Army in Jamaica, 
etc. By William Lempriere. London, 1799. 2 vols. pp. 652. 
Lempriere w^as regimental surgeon, and superintendent of the 
military hospitals, in Jamaica, from 1792, to 1797. His book is 
well and sensibly written. He calls yellow fever tropical con- 
tinned fever ; recognizes and insists upon its essential unlikeness 
to bilious remittent fever, and denies its contagiousness. His de- 
scription of the disease is very good. His treatment consisted 
mostly in the warm bath, a mercurial purgative, and cinchona. 
His chapter on the pathology of yellow fever is wholly hypotheti- 
cal and speculative, and of no value whatever. 

An Essay on the Malignant Pestilential Fever, introduced into 
the West Indian Islands, from Boullam, on the coast of Guinea, as 
it appeared in 1793, 1794, 1795, and 1796, etc. etc. ByC. Chis- 
holm, M. D. Dr. Chisholm was a resident at Grenada during the 
prevalence in that island of the disease which he describes. He 
may be looked upon as the leader of the contagionists, andhew^as 
one of the most earnest advocates of the mercurial treatment of 



BIBLIOGRAPHY— JACKSON. 521 

yellow fever. His account of the introduction of the disease into 
Grenada has already been given. His description of the disease 
is anything but clear and complete. He looked upon the new 
fever as essentially distinct from the ordinary yellow fever of the 
West Indies ; and he seems to have been constantly haunted by 
the notion of its close resemblance to the Oriental plague.-^ His 
work constitutes an interesting portion of the history and literature 
of yellow fever, notwithstanding its incompleteness and one-sided- 
ness.^ The distinctions which he endeavors to make out between 
the two diseases are altogether fanciful, as well as his speculations 
upon their causes. His treatment was founded upon what he 
calls reasoning and reflection. 

A Sketch of the History and Cure of Febrile Diseases in the 
West Indies. By Robert Jackson, M. D. London, 1820. 2 vols. 
2d ed. There is hardly any work on the diseases of the West 
Indies which has enjoyed a more extensive celebrity than this; 
and there is none which has less real value. There are some in- 
dications in it of good sense ; but its leading characteristics are 

* After pointing out this resemblance in detail, the Doctor winds up with the 
very sage and satisfactory- conclusion, that yellow fever is quite like the plague, 
except^ that it does not always exhibit the symptoms of the latter malady ! 

2 There is a good deal of inherent evidence in Dr. Chisholm's book, that much 
of what he says is to be taken with some grains, at least, of allowance ; even 
when he supposes himself to be relying upon the clear evidence of his own senses. 
In his account of the first autopsy that he made, he says, — " the upper part of the 
cranium, on being sawed and prized up by a chissel, was so pressed from inwards 
by the distention of the cerebrum as to fly off, or separate in such a manner as if a 
spring from within acted upon it." The worthy Doctor believed, also, in the ex- 
istence of the mermaid, with all the interesting and lady-like qualities usually as- 
signed to her ; the head, like that of the human species, but rather smaller, some- 
times bare, but oftener covered with an abundance of long, black hair; the shoulders 
broad, and the breast large, and well-formed ; the tail, fish-like, and forked, and so 
on. These creatures were generally seen in a sitting posture in the water, their 
tails very properly out of sight; and always employed in smoothing their hair, 
or stroking their breast and faces with their hands. They are held in great ve- 
neration by the natives, and this is the reason that none of them have ever been 
shot. Such is the account which a Mr. Van Battenburgh gave to Dr. Chisholm, 
and which greatly diminished the skepticism of the latter in regard to this sub- 
ject. — Chisholm's Essay, vol. ii. p. 192. The Doctor thinks it not a little singular, 
that, in yellow fever, a very distressed feeling about the heart, — probably a smo- 
thering of the heart, — should be peculiar to the natives of Ireland! Some notion 
of Dr. Chisholm's skill in diagnosis may be derived from the fact of his describing 
what he calls an Epidemic Polypus, prevailing at Grenada, and characterized by 
the presence of long polypi in the heart and large blood-vessels. 



522 YELLOW FEVER. 

these, — a wretched want of all diagnosis; a spurious and misera- 
ble medical philosophy; an extravagant system of practice; and, 
runnino- through the whole, an utterly unmeaning or unintelligible 
jargon. Dr. Jackson's medical philosophy appertains to the same 
school and class as that of Dr. Rush. He calls yellow fever, pneu- 
monia, scrofula, and chronic ulcers of the legs, forms^ merely, of 
febrile disease, — a kind of pathological unitarianism. that would 
have delighted the heart of the great American. 

The second volume of Dr. Rushes Medical Inquiries is mostly 
devoted to the yellow fever. The author was one of the leading 
medical men in the city of Philadelphia, during the prevalence of 
the disease there, in 1793, and subsequently; he studied it with 
zeal and enthusiasm ; he took a very prominent part in the dis- 
cussions which arose, especially in regard to its causes, and its 
treatment; and his high position and wide reputation gave to his 
opinions great weight and authority. His account of the epidemic 
of 1793 occupies more than one hundred and fifty pages. It is 
immethodical and fragmentary; but it contains much valuable 
material for the history of the disease, and will always be read 
with interest and instruction. At the commencement of the epi- 
demic. Dr. Rush adopted the treatment recommended by Dr. Ste- 
vens, by Peruvian bark, and the cold affusion. Three out of four 
of his patients died. He meditated and studied ; and the first 
rays of the true light, as he regarded it, seem to have been derived 
from a manuscript account of the yellow fever of Virginia, in 
1741. He now began the use of calomel and jalap, and four of 
his first five patients recovered. He assured his fellow-citizens, 
that the disease was no longer incurable. He soon added to this 
treatment, bleeding, cool air, cold drinks, low diet, and cold water 
externally. "Never before," — exclaims the enthusiastic philan- 
thropist, — " did I experience such sublime joy as I now felt in 
contemplating the success of my remedies. It repaid me for all 
the toils and studies of my life." The most lamentable defect in 
these histories of the yellow fever consists in the absence of all 
accurate diagnosis. A case of ordinary menorrhagia, or colic, is 
called a form of yellow fever ! This defect, with a most unphi- 
losophical passion for hasty and unwarrantable generalization, 
takes away much of the value which these histories would other- 
wise possess. 

A Short Account of the Malignant Fever, lately prevalent in 



BIBLIOGRAPHY.— M. CAREY.— CURRIE. 523 

Philadelphia, etc. etc. By Matthew Carey. 4th ed. Philadelphia, 
1794. This is an interesting history, — moral, social, and statistical, 
rather than medical, of the epidemic of 1793, written by a sensi- 
ble and judicious man, not of the profession. The picture of the 
scene is very vividly and graphically drawn, — the common picture 
of pestilence, with its shapes of darkness, and its shapes of light; 
abject terror, selfishness, and inhumanity, strangely mingling and 
contrasting with the boldest courage, self-forgetfulness, and love 
stronger than death. A large hospital was established at Bush- 
hill. It was crowded with the sick and dying, whose perils and 
sufferings were increased for want of suitable nurses and attend- 
ants. Amongst those whose personal services were voluntarily 
offered, was a rich merchant, a native of France. He took charge 
of the sick wards; reformed the whole character of the service; 
encouraged and solaced the patients ; held the cup to their parched 
lips; wiped the cold sweat from their pale foreheads; and shrunk 
from no menial office that could mitigate or soften their distresses. 
This was Stephen Girard ; and this simple memorial of him, in 
the pages of Mr. Carey, is a nobler and prouder monument to his 
memory, than that marble temple, — magnificent and beautiful as 
it is, — which now bears his name. 

Memoirs of the Yellow Fever of Philadelphia, in 1798. By 
William Currie. Philadelphia, 1798. This is a kind of desultory 
diary of the yellow fever visitation of 1798, — a record from day 
to day, of some of the principal events and incidents of the epi- 
demic. Although public attention and medical research have 
been more particularly directed to the Philadelphia fever of 1793, 
it appears that the epidemic of 1798 was absolutely nearly as 
destructive as the former, and relatively much more so. The 
disease, in the latter year, was more malignant and fatal, than in 
the former; the total mortality was nearly four thousand, although 
three-quarters of the inhabitants are estimated to have left the 
city. This year, the disease prevailed more generally along the 
northern than along the southern coast. Dr. Rush has a letter in 
the book, referring fatal cases to the stagnation of acrid bile in the 
gall-bladder, or its close adherence to the upper bowels; and recom- 
mending an artificial cholera morbus, excited about the fourth day 
of the fever, by shaking the gall-bladder and bowels, and discharg- 
ing their contents, with tartar-emetic, gamboge, jalap, and calomel, 
and perhaps Turpeth mineral! "As there is a blistering point," 



524 YELLOW FEVER. 

— says the philosophical doctor, — "in all fevers, so there appears 
to be an e?netic point in the yellow fever!" Dr. Currie thinks 
that the fever was introduced into Philadelphia, in the ship Debo- 
rah, from the West Indies. " The contagious nature of the 
fever," — he says, — " is acknowledged by all, excepting a few 
persons that are distinguished for nothing but the singularity of 
their opinions, and a pertinacious adherence to a tenet, which 
both by the illustrations of reasoning, and the common sense of 
their fellow-citizens, has been declared absurd and untenable." 

A View of the Diseases most prevalent in the United States of 
America, etc. By William Currie. Philadelphia, 1811. 1 vol., 
pp. 240. 

Observations on the Causes and Cure of Remitting or Bilious 
Fevers, etc. By William Currie. Philadelphia, 1798. 1 vol. 
Both these little volumes of Dr. Currie's are marked throughout 
by careful observation, by a correct philosophy, and by sound 
sense. Dr. Currie was a cotemporary of Dr. Rush, and a prac- 
titioner in the same city. His general descriptions of disease are 
quite as good, to say the least, as those of his distinguished fel- 
low-citizen, and his medical philosophy infinitely sounder and 
more rational. He recognized clearly the radical difference be- 
tween bilious remittent, and yellow fever. He was a qualified 
contagionist, advocating nearly the same doctrines that were sub- 
sequently adopted by Dr. Hosack and others. 

Traite de la Fievre Jaune. Par Jean Deveze. Paris, 1820 : pp. 
311. Dr. Deveze established himself, as a physician, in St. 
Domingo, in 1778, After a successful and prosperous career of 
fifteen years, he saw his fortune suddenly wTecked by the insur- 
rection in that country; and he was forced to flee for his life. He 
arrived in Philadelphia in August, 1793, and was almost imme- 
diately actively engaged in the treatment of the epidemic then 
prevailing. He was appointed one of the physicians of the hos- 
pital at Bush Hill; but the other medical men refused to be asso- 
ciated with him ; they resigned their places, and he took charge 
of the institution. Dr. Deveze remained in Philadelphia four 
years, so that he saw the two great epidemics of 1793, and 1797. 
He had also been acquainted with the disease in its sporadic form, 
for fifteen years in St. Domingo. In 1794, he published a short 
essay, clearly and strongly controverting the then almost universal 
and popular doctrine of the contagious character of the disease. 



BIBLIOGRAPHY.— BURNETT. 525 

In 1797, he reiterated his opinions in a letter to Governor Mifflin. 
His description of the disease, as it showed itself in 1793, is short 
and general, but very vivid and clear. A large portion of Dr. 
Deveze's book is devoted to a consideration of the causes of yel- 
low fever; and it is his leading object to show that the disease is 
infectious, and not contagious. He is sometimes unsound and un- 
philosophical in his doctrines, — as for instance when he insists 
upon the identity of all infections or malarial poisons,- — but his 
book is generally characterized by great fairness, ability, and good 
sense. He whites in a clear, strong, and pure style, and he is 
entirely free from personalities, and from all professional puppy- 
ism, — which is something in a ^vork of medical controversy. Dr. 
Rush was a staunch contagionist for several years after the publi- 
cation of Dr. Deveze's essay upon this subject. He at length 
changed his opinions, avow^ed what he considered his former 
errors; and assigned his reason for the change; hut no allusion, 
whatever y is 7nade hy him to the writings or opinions of Dr. De- 
veze; his name is not even mentioned by Dr. Rush! 

During the first period of the disease. Dr. Deveze gave diluent 
and effervescing drinks, bled very moderately, and made use of 
warm baths, enemata, and emollient applications to the epigas- 
trium. He sometimes applied cold water to the abdomen, and to 
the head. If the disease did not abate, he gave light diffusible 
stimuli, especially sulphuric ether and camphor. To these he 
added nitre. In the second stage, he continued these remedies, 
and added a bitter and tonic infusion, usually of serpentaria and 
cinchona. He also applied blisters and sinapisms; opened the 
bowels wath mild purgatives ; and gave animal broths and rice 
water, to w^hich wine was sometimes added. In the stage of col- 
lapse, the tonic and stimulant remedies were continued, and hot 
applications w^ere made to the limbs. 

^ Practical .Account of the Mediterranean Fever, etc. By 
William Burnett, M. D. London, 1816. 1 vol. p. 522. Dr. Bur- 
nett w^as attached to the British fleet, on the Mediterranean sta- 
tion, for a period of more than ten years, in the early part of the 
present century. During this time, he had repeated and exten- 
sive opportunities of studying yellow fever, mostly on ship-board, 
and in the naval and military hospitals. His description of the 
disease is very good ; but like that of nearly all other waiters, 
very short, and in general terms. His two leading ideas are the 
non-contagious nature of the disease, and the great efficacy of 



526 YELLOW FEVER. 

early and free bleeding, in its treatment. In an appendix of more 
than a hundred pages, he criticizes, with a good deal of asperity, 
the doctrines and opinions of Mr. Pym, — attributing to him self- 
ish and mercenary motives, and accusing him of wilful misre- 
presentations. The book, altogether, has but little method in its 
plan and arrangement; and adds but little to our accurate know- 
ledge of yellow fever. Like most of the polemical writings upon 
this subject, it is too thoroughly partisan in its character to be 
entirely trusted. 

An Essay on the Disease, called Yellow Fever, etc. etc. By 
Edward J\^athamel Bancroft, M.D., etc. London, 1811. 1 vol. 
pp. 811. Dr. Bancroft is a strong and unqualified non-con- 
tagionist. He saw something of yellow fever in the West Indies; 
but does not seem to have studied the disease, — except in its 
etiology, — with any special care, or attention. His remarks on 
its symptoms, pathology, and treatment are brief, and in no way 
of any great value. The second part of the essay is devoted to 
the purpose of showing that animal putrefaction, filth, the crowd- 
ing: of persons together in close, unventilated apartments, and so 
on, are incapable, alone, of giving rise to contagious fevers, such 
as typhus. Dr. Bancroft, like m.ost of the non-contagionists of 
his day, regarded yellow fever as a high grade, merely, of bilious 
remittent fever. He calls the belief in contagion anti-social and 
barbarous ; and his examination of the opinions of Dr. Chisholm, 
in connection with the Hankey, are marked by a good deal of bit- 
terness and asperity. Dr. Bancroft shows very clearly, I think, 
that the disease which affected the crew and people of the Han- 
key was the remittent, and not yellow fever. 

In 1817 Dr. Bancroft published a sequel to his Essay, in nearly 
five hundred pages. He replies particularly to the work of Dr. 
Pym, and again fights the battle of the Hankey: — 

"And thrice he routed all his foes, 
And thiice he slew the slain." 

The work is systematic and elaborate ; well written, but rather 
prolix and heavy. 

Reports of the Pestilential Disorder of Andalusia, which ap- 
peared at Cadiz in the years 1800, 1804, 1810, and 1813, etc. etc. 
By Sir James Fellowes, M.D. London, 1815. 1 vol. pp. 484. 
Sir James Fellowes was at the head of the medical department of 
the British armies in the Peninsula, during the war with France. 



BIBLIOGRAPHY— BLANE. 527 

He is a decided, but dispassionate, and rational advocate of the 
doctrine of contagion. He saw yellow fever, at dilTerent places 
in Spain, but mostly at Cadiz and Gibraltar. There is no evi- 
dence, in his book, that he had studied the disease with any great 
care or thoroughness ; and he has hardly added anything to its 
natural history. The proofs which he adduces of its contagious- 
ness, and which he calls incontrovertible, seem to me to be any- 
thing but such. He copies from Arejula, a very good general 
description of the disease, as the latter saw it at Cadiz in 1800. 
The temper and style of his book are dignified and gentlemanly; 
and this is something in a controversy which has sometimes been 
conducted, to use his own words, " with an asperity of lan- 
guage, alike disreputable to science, and injurious to philosophical 
inquiry." 

Elements of Medical Logic. By Sir Gilbert Blane. London, 
1829. The latter part of this very elegant and philosophical 
essay is devoted to a vindication of the contagious character of 
yellow fever; and no one acquainted with the previous writings 
of the author, or with his clear, acute, and logical mind, could 
doubt, for a moment, that the vindication would be made not only 
with fairness, and candor, but also with signal ability. Blane 
himself had seen but little of the disease; it rarely occurred dur- 
ing his service on the West India station ; and his convictions 
are, for the most part, the result of a careful and conscientious 
examination of all the trustworthy evidence which he was able to 
procure. It is not improbable, that in some remarks upon the 
report of the French Commissioners to investigate the disease at 
Cadiz, he may have had some reference to his own position. "It 
has been objected," — he says, — "that those commissioners were 
not on the spot when the epidemic prevailed. If this objection 
were well founded, it would go to invalidate all judicial investi- 
gations whatever. It is not deemed a necessary qualification for 
a judge on the bench, that he should have been actually present 
at the transactions upon which he is to decide. On the contrary, 
by an accurate and comprehensive survey of the points and bear- 
ings of a complex case, he is better qualified to form an opinion, 
than the actual actors in them, besides being divested of preju- 
dice. It is requisite, for the forming of a clear, calm, and impar- 
tial judgment, that objects whether natural or moral, should be 
placed at a certain distance, in order that they may be seen in 



528 YELLOW FEVER. 

those relative positions and bearings, which the eye and mind of 
a close observer, or of a party concerned, is incapable of taking 
in." The general argument for the contagiousness of yellow 
fever is clearly, fairly, systematically, earnestly, and strongly 
stated. The opposite doctrine he calls "a deplorable and mis- 
chievous delusion,''^ and the reasons upon which it rests, " a piece 
of cavilling sophistry. '^'^ "The question," — he says, in conclu- 
sion, — "seems now to be brought to such a point, that we may 
venture to challenge any candid, intelligent and unbiassed man, 
whether in or out of the profession, to open his eyes, and deny 
that this disease is contagious; and if it be not, then has the 
author of this discussion lost every faculty of distinguishing truth 
from falsehood, of discerning light from darkness." 

Observations and Inquiries into the JVature and Treatment of 
the Yellow or Bulam Fever, etc. By Edward Doughty. London, 
1816. 1 vol. pp. 238. Mr. Doughty was in the medical service 
of Great Britain, in Jamaica, during a period of eight years, at 
the beginning of the present century; and he was at Cadiz in the 
epidemic season of 1810. He was one of the surgeons in the 
staff under Sir James Fellowes; he wished to study the pathology 
of yellow fever, by examinations after death, to which objections 
were made by the latter; Dr. Doughty was guilty of some alleged 
rudeness towards his official superior, and was in consequence 
dismissed from the service. There is nothing new in his book. 
He is an advocate for early bleeding ; and a zealous non-con- 
tagionist. 

Observations on the Inflammatory Endemic, commonly called 
Yellow Fever, etc. By J\''odes Dickinson. London, 1819. Mr. 
Dickinson was extensively familiar with the disease, about which 
he writes, during a practice of twenty years, in the West Indies. 
His work is diffuse, and of no special value. 

Results of an Investigation respecting Epidemic and Pestilential 
Diseases, etc. By Charles Maclean, M. D. London, 1817. 2 
vols. pp. 1016. My only motive for including this work in my 
bibliography of yellow fever is to guard my readers against buy- 
ing or attempting to read it. In all medical literature, it would 
be difficult finding a noisier, emptier, or more arrogant, egotistical, 
and puppyish book than this. 

Du Typhus d^Anierique, ou Fievre .Jaune. Par Vr. Bally. Paris, 
1814. Pp. 623. This is a systematic treatise on yellow fever, by 



BIBLIOGRAPHY.— PYM.—0'HALLORAN. 529 

a French physician, who seems to have had extensive opportunities 
for studying the disease in the West India islands. He is a con- 
tagionist. He made a considerable number of autopsies. The 
liver, he says, was frequently natural ; yellow in two cases, and 
pale in one. His description of the disease is systematic, detailed 
and admirable. His treatment has nothing very special; it is 
moderately antiphlogistic during the first stage; and stimulating 
and cordial subsequently. 

Observations upon the Bulam Fever, etc. etc. By William 
Pym, Esq. London, 1815. Pp. 307. This work is made up 
of running and desultory commentaries upon various subjects con- 
nected with yellow fever. The author examines at considerable 
length, and endeavors to controvert, the opinions of Dr. Bancroft, 
and Dr. Burnett. He is a very zealous contagionist ; and he finds 
one of the strongest grounds for his opinion on this subject in the 
non-liability of persons to second attacks of the disease. He is 
no friend to the lancet. 

Remarks on the Yellow Fever of the South and East Coasts of 
Spain, etc. By Thomas 0"* Halloran, M. D. London, 1823. Pp. 
208. Dr. O'Halloran was for many years connected with the 
medical service of the British government; and had frequent op- 
portunities of seeing yellow fever, in the West India islands, and 
in Spain. During the extensive and malignant epidemic of 1821, 
he visited many of the principal yellow fever localities of the South 
and East coasts of Spain, for the express purpose of studying the 
disease. The book before us is the fruit of these studies. It con- 
tains medico-topographical sketches of Barcelona, Tortosa, Malaga, 
Puerto de Santa Maria, Xerez, Lebrixa, San Lucar, and Cadiz; 
with remarks on the origin and causes of the epidemic in these 
several towns, and cities. The author is a zealous and unquali- 
fied non-contao^ionist. 

Less than twenty pages, constituting, however, a very interest- 
ing and valuable portion of the book, are occupied with an account 
of his pathological researches in yellow fever. He says that he 
had seen more than two hundred dissections in this disease ; but 
he reports only eleven. Sufficient reference to these has already 
been made. He says that the examination of yellow fever sub- 
jects ought to take place as soon as possible after death ; since the 
different organs, and more particularly those which have suffered 
34 



530 YELLOW FEVER. 

from the disease, undergo changes in a few hours, so as to become 
brown, black, and apparently gangrened. 

Essays on Vaiious Subjects of Medical Science. By David 
Hosack,M.D., F.R.S., etc. JYew York, 1824: 2 vols. The 
first volume of these miscellaneous Essays contains Dr. Hosack's 
Observations on the Laws which govern the communication of 
Contagious Diseases. The leading objects of the Essay are to 
show, that yellow fever is not the product of miasmata, or of any 
animal or vegetable decomposition ; but that it depends upon a 
specific virus, which is generated by the disease in the human body ; 
and that this virus, when introduced into a local atmosphere already 
vitiated by vegetable and animal impurities, is endowed with the 
property of indefinitely multiplying itself; or, in other words, by 
a kind of fermentative process, assimilating the impure atmo- 
sphere to itself. In this atmosphere, according to Dr. Hosack, 
but not elsewhere, yellow fever- is communicable from the sick to 
the well. 

Observations upon the Autumnal Fevers of Savannah. By W. 
C. Daniell, M.D. Savannah, 1826. The principal purposes of 
Dr. Daniell's publication are, to state some new views of the na- 
ture and pathology of autumnal fevers, and to recommend a some- 
what novel method of treatment. The former consist altogether 
of hypothetical rationalism ; and the chief element of the latter 
consists in producing extensive and continued inflammation of 
the skin by sinapisms. All success in the treatment of autumnal 
fever, yellow fever included, depends upon this inflammation of 
the skin. What leeches were to Broussais ; what the lancet is to 
Bouillaud ; and what quinine is to many of our southwestern phy- 
sicians, sinapisms are to Dr. Daniell. His other remedies are 
capsicum, serpentaria, and Peruvian bark. He insists earnestly 
upon the congestive and non-inflammatory nature of yellow fever; 
and he argues that all its phenomena, symptomatical and patho- 
logical, go to corroborate this doctrine. He is opposed to bleed- 
ing, to mercurials, and to active purging. 

Memoirs of the West Indian Fever, Sfc. &fc. By John Wilson, 
M. D., R. M. London, 1827. Pp. 217. This is one of the great 
numbers of valuable contributions which have been made to 
medical science by the medical oflicers of the British army and 
navy. Like most other works of the class to which it belongs, it 
is partial in its designs, and somewhat fragmentary in its charac- 



BIBLIOGRAPHY.— CHERVIN. 531 

ter; it does not profess to be a systematic treatise on the subject 
with which it is concerned, but it furnishes valuable materials for 
the construction of such a treatise. It consists of five separate 
Memoirs. The first is devoted to a general description of the 
several forms of yellow fever; and to the methods of treatment 
which they respectively require. Dr. Wilson's descriptions I 
have already quoted. In the inflammatory forms, he is a bold 
and active bleeder ; in the congestive forms, he has little faith in 
remedies, bat would try hot and stimulating applications to the 
skin ; w^arm, aromatic, and cordial drinks, a warm purgative, and 
calomel in large and repeated doses. 

In the second Memoir, Dr. Wilson examines some of the lead- 
ing opinions in regard to the causes of yellow fever, especially 
those which have referred the disease to atmospheric heat, to con- 
tagion, to marsh miasmata, and to the principle of vegetation. 
All these opinions he rejects. 

In the third Memoir, he states his own opinions about the cause 
of the disease. He suggests, in the first place, that this cause 
may be in some way connected with a calcareous formation of 
the soil, since the principal yellow fever localities in the West 
Indies, he says, have a soil of this character. The essential 
cause, he believes, is furnished by wood, consisting in a gaseous 
product of trees and shrubs, in a state of decomposition, generally 
given out by them in a cut or dried state, but which may arise 
from a living forest, trees being capable, in different parts of their 
frame, of simultaneous growth and decay. 

In the fourth Memoir, Dr. Wilson states very clearly some of 
the more obvious reasons for regarding yellow fever as a distinct, 
specific disease, and not an aggravated variety of merely bilious 
remittent. 

The fifth Memoir consists of a few remarks upon the nature of 
yellow fever, and upon the manner in which the cause of the 
disease acts upon the body. Of course it is mostly hypothetical; 
but it is less unreasonable than most speculations of a similar 
character. 

De /' Opinion des Medecins Americains sur la Contagion ou la 
JYon- Contagion de la Fievre Jaune, etc. etc. Par JY. Chervin. 
Paris, 1829. Pp. 192. It is hardly worth while to enumerate the 
titles of all the different works published by M. Chervin on the 
subject of the yellow fever. The character of these works, and 



532 YELLOW FEVER. 

the history of his life and labors are well known to all those who 
have made this disease a subject of study. He was the great 
champion of non-contagion in the Old World; and nearly the 
whole of the five volumes which he published between 1827, and 
1840, is devoted to the vindication of his favorite doctrine. The 
volume whose title I have given is mostly taken up with his re- 
plies to Dr. Hosack and Dr. Townsend of New York. It is pain- 
ful and humiliating to witness the violence and harshness of this 
controversy. 

Anatomical, Pathological, and Therapeutic Researches on the 
Yellow Fever of Gibraltar, o/l828. By P. Ch. A. Louis. Bos- 
ton, 1839. Pp. 374. The history of this remarkable work is well 
known. It was first presented to the public, in an English trans- 
lation, by Dr. G. C. Shattuck, jr., of Boston, in 1839, more than 
ten years after its materials were collected. Since that time, it has 
been published in the original French, in the second volume of the 
Transactions of the Medical Society of Observation. It does not 
profess to be a systematic treatise on yellow fever ; indeed it is 
only a partial history of a single epidemic, — many points in the 
natural history of the disease being wholly omitted. Still, as a 
description of the symptoms and lesions of yellow fever, it is of 
very great value, and no history of the disease can be rendered 
complete without constanct reference to its pages. 

The JVew Orleans Medical Journal contains numerous papers on 
yellow fever, some of which are of much value; — they have al- 
ready been laid under liberal contribution in the preceding his- 
tory. I will briefly refer to the principal ones amongst them. 
First, an Essay on Yellow Fever, by J. F. Beugnot. It is written 
in the English language, but in the French idiom; and is the 
work, I presume, of a French physician. • It is mostly taken up 
with the subject of treatment. Dr. Beugnot's leading object is to 
show the importance of what he calls syncopal blood-letting in the 
treatment of yellow fever. He gives to Dr. Luzenburg the credit 
of originating this practice. The evidence of the efficacy of this 
method consists merely in general assertion, and is of course in 
no degree conclusive or satisfactory. Second, An Account of the 
Yellow Fever at Rodney, in 1843, by Dr. Williams and Dr. An- 
drews. Rodney is a small town on the east bank of the Missis- 
sippi, forty miles above Natchez. It was visited by the yellow 
fever, for the first time, in 1843. The authors of the paper be- 



I 



BIBLIOGRAPHY.— COOKE. 533 

lieve that the disease did not originate from local causes, but was 
introduced from New Orleans. Third, an article by Dr. Lambert, 
of twenty pages. This is in good })art, an attempt to give the rea- 
sons of many of the phenomena and relations of the disease; and 
it is as successful and satisfactory, perhaps, as such attempts usu- 
ally are. Fourth, Thoughts on Yellow Fever, etc., by Dr. P. H. 
Lewis, 0/ Mobile. This is a reply to the arguments of Dr. Mo- 
nette and Dr. Carpenter, who advocate the transportability of the 
poison of yellow fever. Dr. Lewis does not admit that it ever 
possesses this property. Fifth, A Report on the Yellow Fever at 
Woodville, by Dr. De Valetti, and Dr. Logan. Woodville is a 
small inland town in the State of Mississippi, about fifteen miles, 
in a direct line, from the Mississippi river. In 1844, it was visited 
by yellow fever, and the usual ditferences of opinion arose in re- 
gard to the cause and origin of the disease. In this paper, it is 
ascribed to domestic sources. Sixth, Sketch oj" the Yellow Fever 
of Mobile, etc., by P. H. Lewis, Al. D. This sketch consists of two 
long articles. Notwithstanding its want of method, and its hasty 
preparation, it contains much matter of importance and value. I 
have made free use of its materials, in the preceding history. 
Seventh, ^S Report by Dr. Stone, on the Origin of the Woodville 
Epidemic, with a discussion growing out of the Report, before the 
Louisiana Medical Society. Dr. Beugnot states that Woodville 
possesses in the highest degree every condition essential to salu- 
brity; — a silicious soil, an elevated position, a dry atmosphere, 
moderate temperature, and so on. He is a decided anti-conta- 
gionist ; but he is not less decided in his conviction, that the 
seeds of the poison may be transported from one place to another, 
— multiplying and extending themselves in the locality where they 
are introduced. He advocates quarantine for ships, and their car- 
goes, but not for persons. Dr. Luzenburg expresses his suspi- 
cions that the fever at Woodville was introduced from New Or- 
leans, or Bayou Sara, during the present year, in boxes of mer- 
chandize, or possibly some years previously in goods which had 
not been opened. Dr. Stone's report contains a full account of 
the Woodville epidemic. 

In the second volume, there are the following papers: — First, 
Practical Remarks on the Yellow Fever which prevailed at Ope- 
lousas, in 1837, 1839, and 1842; by Dr. Cooke. Dr. Cooke be- 
lieves that the poison of the disease is generally introduced from 



534 YELLOW FEVER. 

New Orleans. Second, a sketchy, interesting, sensible paper, his- 
torical, topographical, critical, and so on, by Dr. Dowler of New 
Orleans. Third, Remarks on Yellow Fever^ by Dr. Harrison. 
The author praises, almost extravagantly, the sulphate of quinine. 
He deprecates, in the strongest terms, the mercurial practice ; 
and says that general bleeding is only an exceptional remedy, and 
always to be used with great caution and reserve. Fourth, An 
Account of the Yellow Fever at A''ew Orleans, in 1846, hy Dr. 
Fenner. The author concludes that the disease was of domestic 
origin ; and that the prevalence of summer fevers in the city is 
not in proportion to the amount of heat, moisture, and putrid mat- 
ters. Fifth, Cases, showivg the effect of Yellow Fever on the Sys- 
tem, for a long penod after an attack; hy Dr. Stone, of JVatchez. 
This is an important subject ; but the cases given by Dr. Stone 
can hardly be regarded as conclusive. Sixth, An Account of the 
Yellow Fever at Woodville; hy Dr. Stone, of Woodville. The 
most singular thing in this paper is the unqualified confidence 
with which the writer speaks of his method of treatment. He 
bled, at the beginning, freely and repeatedly; and then gave what 
he calls sedative doses of calomel, — usually from forty to sixty 
grains. This remedy, thus used, Dr. Stone regards as a specific 
just as absolute and efficacious in yellow fever, as quinine is in 
intermittentsl 

There are several interesting and valuable articles in the Ame- 
rican Journal of Medical Sciences ; by Dr. E. H. Barton, Dr. E. 
B. Harris, Dr. Barrington, Dr. Nott, and others. 

The article in the Cyclopedia of Practical Medicine, is by Dr. 
J. Gillkrest. The author begins with quotations from Dr. Rush, 
and from British and Spanish physicians, tending to show that 
yellow fever sometimes assumes a remittent type. He next gives 
a short but interesting historical sketch of the disease in Europe 
and America, showing clearly enough that yellow fever prevailed, 
often and extensively, as long ago as the sixteenth and seventeenth 
centuries. Dr. Gillkrest is a strong anti-contagionist ; and he de- 
tails many striking facts which fell under his own observation at 
Gibraltar, in proof of his opinions on this subject. He seems to 
think highly of the mercurial treatment. 

The paper in the Lihrary of Practical Medicine is by Dr. Shap- 
ter. It is much shorter, and less elaborate, than that of Dr. Gill- 
krest. 



INDEX 



Abdomen, state of, 

bilious fever in, 319. 

typhoid fever, 57. 

typhus fever, 186. 

yellow fever, 420. 
Abdominal lesions, 

periodical fever in, 327. 

typhoid fever, 68—79. 

typhus fever, 198—202. 

yellow fever, 434 — 445. 
Abdominal pains, 

typhoid fever in, 56. 

typhus fever, 187. 

yellow fever, 420. 
Abdominal symptoms, 

bilious fever in, 316—321. 

congestive fever, 358. 

typhoid fever, 52 — 58. 

typhus fever, 184—188. 

yellow fever, 417—421. 
Abdominal typhus, 34, 254. 
Access, mode of, 

bilious fever, 306. 

congestive fever in, 353. 

typhoid fever, 39, 114. 

typhus fever, 174 

yellow fever, 411. 
Access, period of, 

periodical fever in, 309. 

yellow fever, 412. 
Acclimation, 

periodical fever in, 350. 

yellow fever, 460. 
Affusions and ablutions, 

congestive fever in, 388. 

typhoid fever, 148, 150. 

typhus fever, 284, 

yellow fever, 510. 
African fever, 402. 

climate, 404. 

diseases, 404. 
Age, influence of, 

periodical fever on, 344. 

typhoid fever, 100, 118, 249. 

typhus fever, 217, 231, 249. 

yellow fever, 456, 497. 
Algid fever, 356. 

Alteratives in typhoid fever, 146, 160. 
Alum in typhoid fever, 159. 
Anderson, Dr., 330. 
Andral, 130, 132. 
Andral and Gavarret, 65. 
Anemia, 367, 395. 



Aniraalcular hypothesis, 347. 
Animal decomposition, 347, 467. 
Annesley, Dr., 401. 
Antimony, 

typhoid fever in, 143,147. 

typhus fever, 287. 
Antiphlogistic treatment, 

yellow fever in, 508. 
Aorta, lesions of, 64. 
Appetite, 

bilious fever in, 317. 

typhoid fever, 54. 

typhus fever, 185. 

yellow fever, 417. 
Armstrong, Dr., 210, 245. 
Arnold, D'r., 443, 444. 
Arrott, Dr., 208, 218. 
Autenrieth, Dr., 254. 

Bancroft, Dr., 508, 526. 

Bailly, Dr., 325, 400. 

Bally, Dr., 528. 

Barbour, Dr., 387. 

Barker, Dr., 172, 295. 

Barrington,Dr.,411, 478, 

Bateman, Dr., 235, 296. 

Bed-sores, 152 

Beugnot, Dr., 532. 

Bibliography of periodical fever, 398 — 405. 

Alibert, 399. 

Annesley, 401. 

Bailly, 400. 

Boyle, 404. 

Brown, J,, 405. 

Cleghorn, 398. 

Johnson, J., 399. 

Lind, James, 399. 

Macculloch, 400. 

Maillot, 401. 

M'William, 402. 

Senac, 398. 

Shapter, 405. 
Bibliography of typhoid fever, 164 — 168. 

Chomel, 167. 

Forget, 167. 

Hale, 167. 

Jackson, J., 167. 

Louis, 166. 

Prost, 164. 

Smith, N., 166. 
Bibliography of typhus fever, 293—299. 

Barker and Cheyne, 295. 

Bateman, 296. 



536 



INDEX. 



Bibliography of typhns fever — continued. 
Cheyne, 299. 

Christison, 298. 

CJatterbnck, 294. 

Cormack, 298. 

Gaoltier de Claabry, 297. 

Hartv. 295. 

HUdenbrand, 294. 

Jackson, R., 296. 

Mills, 294. 

Percival, 297. 

Pricbard, 297. 

Pringle, 293. 

Trotter. 293. 

Tweedie, 299. 
Bibliography of yellow fever, 51 S — 534. 

Amer. journ. of Med. Sci., 534- 

Baily, 528. 

Bancroft, 526. 

Blane, 518,525. 

Burnett, 527. 

Carey, 523. 

Chervin, 531. 

Chisbolm, 520. 

Currie, Wtn., 523, 524. 

Daniel'], 530. 

Deveze, 524. 

Dickinson, 52S. 

Docghty, o2S. 

Fellowes. Sir J.. 526. 

Gi]lkrest,'534. 

Hillary, 519. 

HosacV, 530. 

Hunter, J., 520. 

Jackson, R., 521. 

Lempriere, 520. 

Louis, 532. 

Maclean, 528. 

Mosely,'519. 

N. 0. Med. Joura., 532. 

0-Halloran, 529. 

Pvm, Sir W., 529. 

Rush, 522. 

Shapter. 534, 

Wilson, 530. 
Bile, character of, 

periodical fever in, 332. 

typhoid fever, 79. 

typhus fev^er, 200. 

yellow fever, 443. 
Bilious remittent fever, 305 — 351. 
Biles in typhoid fever, 62. 
Bis-feriens pulse, 44. 
Black vomit. 419, 435, 438. 
Blane, Sir G., 176, 2&S, 426, 479, 515, 51S, 

525, 527. 
Blisters, 

typhnid fe\eT in, 148, 152, 156, 160. 
Blood-letting, 

bilious fever in, 382. 

congestive fever, 388. 

typhoid ferer, 147, 150, 154, 156, 
* 157. 

typhus fever, 2S0— 284. 

yellow fever, 508. 
Blood, state of, 

periodical fever in, 322. 



Blood, state oP— continued. 

typhoid fever, 65, 140. 

typhus fever, 192, 196. 

veilow fever, 432. 
I Boling, Dr., 306, 311, 314, 319. 
Bonillaad, 157. 
Bowels, state of, 

bilioas TeTer in, 319. 

congestive fever, 358. 

typhoid foTer, 55. 

typhns fever, 186. 

yellow fever, 4^. 
Boyle, Dr., 404. 
Bracken, Dr., 223. 
Brain, lesions of, 

periodical fever in, 323. 

typhoid fever, 67. 

typhns fever, 197. 

y^ow fever, 434. 
Brandy in yellow fever, 512. 
British and Foreign Review, 269, 279. 
Broncbise, lesions of, 

periodical fever in, 322. 

typhoid fever, 66. 

typhus fever, 195. 
Bronssais, 37, 165. 
Brown, Dr. Wm., 290. 
Brunner's glands, 335. 
Bornett, Dr., .505, 527. 
Butter, Dr., 204. 

Calomel, 

bilious fever in, 384. 

congestive fever. 3S7. 

typhoid fever, 143, 146, 14S. 

typhus fever, 284. 

yellow fever, 506 — 50S, 511. 
Calor mordicans, 175. 
Camphor in tvpbus fever, 288. 
Carey, M., 471, 523. 
Causes of death, 

periodical fever in, 339, 3S0. 

typhoid fever, 80. 

yellow fever, 447. 
Causes of periodical fever, 340 — 350. 

age, 344. 

exposure, &c., 346. 

locality, 340. 

malaria, 346. 

race, 345. 

season. 343. 

sex, 345. 

temperature, 343. 

weather, 343. 
Causes of tvpboid fever, S3 — 103. 

age, 100. 

contagion, 9-5 — 98. 

epidemic, 99. 

exposure, fee, 103. 

filth, crowding, &c., 103. 

locality, S3 — 94. 

occupation, 102. 

race, 102. 

recent residence, 102» 

season, 94. 

second attacks, 98, 

sex, 101. 



INDEX. 



537 



Causes of typhus fever, 203 — 219. 

age, 217. 

contagion, 20S— 213. 

crowding, filth, &c., 215. 

epidemic, 214. 

excesses, &c., 215. 

famine, 215. 

fatigue, 215. 

locality, 203. 

recent residence, 219. 

season, 207. 

sex, 218. 

weatlier, 208. 
Causes of yellow fever, 449 — 480. 

acclimation, 460. 

age, 456. 

constitution, 459. 

contagion, 469. 

decaying matters, 467. 

epidemic, 464. 

essential poison, 4S0. 

exposure, &c., 478. 

infected districts, 452. 

locality, 449. 

marsh miasmata, 466. 

occupation, 460. 

race, 458. 

season, 453. 

second attacks, 462. 

sex, 456. 

sporadic, 465. 

temperature, 454. 

weather, 454. 
Cerebral respiration, 44. 
Cerebral symptoms and lesions, 

relations between, 68, 197. 
Cerebro-spinal symptoms, 

bilious fever in, 313. 

congestive fever, 354. 

typhoid fever, 45. 

typhus fever, 179. 

yellow fever, 421. 
Chervin,531. 
Cheyne, Dr. J., 172, 181, 198, 226, 236, 

295. 
Chills, 

bilious fever in, 307. 

congestive fever, 356. 

intermittent fever, 360. 

typhoid fever, 41, 115. 

typhus fever, 175. 

yellow fever, 413. 
Chisholm, Dr., 469, 520. 
Chloride of soda, 

tvphoid fever in, 153. 
Chomel, 40, 107, 138, 149, 167. 
Christison, Dr., 213, 298. 
Cicatrization of intestinal ulcers, 75. 
Cinchona, 

bilious fever in, 384. 

congestive fever, 

typhoid fever, 148, 151. 

typhus fever, 286. 

yellow fever, 51 1. 
Cities, yellow fever, 450, 
Clark, Dr. A., 99. f 



Cleanliness, 

typhoid fever in, 149, 155, 213. 

typhus fever, 213,290. 

yellow fever, 513. 
Cleghorn, Dr., 362, 372, 398. 
Clulterbuck, Dr., 294. 
Coe,Dr., 86. 
Cold atfusions, 

congestive chill in, 388. 

typhoid fever, 148, 150. 

yellow fever, 510. 
Collapse, 

congestive fever in, 356. 

yellow fever, 489. 
Color of skin, 

bilious fever in, 312. 

typhus fever, 192, 222. 

yellow fever, 428, 445. 
Coma, 

congestive fever in, 354. 

typhoid fever, 49, 115. 

typhus fever, 182, 234. 

yellow fever, 424. 
Comatose fever, 354. 
Complications, 

typhoid fever in. 111. 

typhus fever, 220. 
Congestive fever, 352—359. 

algid, 356. 

comatose, 354. 

delirious, 355. 

gastro-enteric, 358. 

mode of attack, 363. 

mortality, 369. 

names, 352. 

prognosis, 369. 

treatment, 386. 

type, 353. 
Constitution, in yellow fever, 459. 
Contagion, 

typhoid fever of, 9.5—98. 

typhus fever, 208—213. 

yellow fever, 469—478. 
Contents of gall-bladder, 

periodical fever in, 332. 

typhoid fever, 79. 

typhus fever, 200. 

yellow fever, 443. 
Contents of stomach and bowels, 

periodical fever in, 338. 

typhoid fever, 70. 

yellow fever, 435, 438. 
Contingent contagion, 473. 
Convalescence, 

yellow fever from, 491. 
Cooke, Dr., 344, 533. 
Cordials, 

typhoid fever in, 145, 151. 

typhus fever, 285. 

yellow fever, 
Core, Dr., 85, 127. 
Cormack, Dr., 298. 
Cough, 

typhoid fever in, 45. 

typhus fever, 178 
Critical days, 365. 



638 INDEX. 



Crises, 221, 224, 225. 
Crowding, 215. 

Currie, Dr. Wm., 398, 523, 524. 
Cutaneous eruptions, 

tvphoid fever in, 59. 

typhus fever, 189—192. 
Cutaneous sensibility, 

tvphoid fever in, 50. 

typhus fever, 183—235. 

Dalton Dr., 203. 
Damaged coffee, 467. 
Daniell,Dr., 530. 
Darwin, Dr., 250. 
Davidson, Dr., 219,263. 
Deafness, 

typhoid fever, 50, 116. 

typhus fever, 183. 
Death, causes of, 

periodical fever in, 339, 380. 

typhoid fever, SO. 

yellow fever. 447. 
Definition, 

periodical fever of, 396. 

typhoid fever, 162. 

typhus fever, 291. 

vellow fever, 516. 
De Haen, 251. 
De Larroque, 158. 
Delirium, 

bilious fever in, 314, 

congestive fever, 355. 

typhoid fever, 47, 115. 

typhus fever, ISO. 

yellow fever, 423. 
Description, methods of, 37. 
Desquamation of cuticle, 43. 
Deveze, Dr., 473, 524. 
Diagnosis, 

congestive fever of, 376. 

periodical fever, 375. 

typhoid fever, 122—133. 

typhus fever, 23S — 276. 

yellow fever, 500 — 502. 
Diaphoretics, 

bilious fever in, 386. 

typhus fever, 287. 
Diarrhoea, 

bilious fever in, 319, 

typhoid fever, 55, 117. 

typhus fever, 1S6. 
Dickinson, Dr., 528. 
Dickson, Dr. S. H., 507. 
Diet, 

typhoid fever in, 144. 

typhus fever, 290. 
Differences between. 

bilious and typhoid fever, 127, 375. 

typhoid and typhus fever, 239 — 276. 
Difficulty of swallowing, 

typhoid fever in, 54, 68, 117. 
Discharges from bowels, 

bilious fever in, 320. 

congestive fever, 358. 

involuntary, 117. 

typhoid fever in, 56. 

typhus fever, 1S7. 



Discharges from bowels — continued. 

yellow fever, 420. 
Distention of abdomen, 

bilious fever in, 319. 

typhoid fever, 57. 
Dizziness, 

bilious fever in, 315. 

typhoid fever, 50. 

typhus fever, 183, 

yellow fever, 423, 
Doane, Dr., 204. 
Dothinenteritis, 34. 
Douglas, Dr., 221. 
Doughty, Dr., 87, 528. 
Dewier', Dr., 464, 534. 
Drinks, 

bilious fever in, 386, 

typhoid fever, 145, 147, 148, 150, 155. 
Duration, 

periodical fever of, 362. 

typhoid fever, 109. 

typhus fever, 223. 

yellow fever, 486, 491. 
Dyspnoea in typhoid fever, 45. 

Easterly winds, influence of, 

yellow fever on, 455. 
Effects of treatment, 

typhoid and typhus fever, 243. 

typhus fever, 290. 
Elliptical plates, lesions of, 

bilious fever in, 335. 

constancy, 127. 

nature of, 136, 140. 

typhoid fever in, 71. 

typhus fever, 199. 
Emaciation, 

typhoid fever in, 58. 

typhus fever, 188. 
Emetics, 

typhoid fever in, 143, 147, 159. 

typhus fever, 288. 
Eneraata, 

typhoid fever in, 143, 150, 155. 
Entero-mesenteric fever, 34. 
Epidemic influences, 

typhoid fever in, 99. 

typhus fever, 214, 234. 

yellow fever, 464. 
Epigastric tenderness, 

bilious fever in, 319. 

typhus fever, 187. 

yellow fever, 420. 
Epiglottis, lesion of, 66. 
Epistaxis, 

treatment of, 152. 

typhoid fever in, 59, 116. 

typhus fever, 188. 

yellow fever, 429. 
Eruptions, cutaneous, 

typhoid fever in, 59. 

typhus fever, 1S9, 192, 235. 
Erysipelas, 62, 111, 118. 
Eschars, 

typhoid fever in, 61, 

typhus fever, 192. 
Essential poison of yellow fever, 480. 



INDEX. 



539 



Ether, 

congestive fever in, 390. 

typhoid fever, 152. 
Exacerbations, 

typhoid fever in, 42. 

typhus fever, 175, 
Exemption from second attacks, 

typhoid fever in, 9S. 

typhus fever, 216. 

yeliow lever, 4G2. 
Expectant treatment, 

typhoid fever in, 147, 150. 
Expedition to the Niger, 402. 
Exposure, excesses, &c., 

periodical fever in, 346. 

typhoid fever, 103, 120. 

yellow fever, 47S 
Eyes, state of, 

typhoid fever in, 50. 

typhus fever, 1S2. 

yellow fever, 426. 

Falling off of hair, 43. 
Famine, 

typhus fever, cause of, 215. 
Fearn, Dr., 391. 
Febrile symptoms, 

bilious fever in, 307. 

typhoid fever, 41. 

typhus fever, 175. 

yellow fever, 413. 
Fellowes, Sir J., 454, 475, 526. 
Fever, 

algid, 356. 

bilious remittent, 305. 

camp, 173. 

comatose, 354. 

congestive, 

contagious, 173. 

hospital, 173. 

intermittent, 359. 

jail, 173. 

malignant, 173. 

periodical, 303. 

petechial, 173. 

putrid, 173. 

remittent, 305 — 352. 

spotted, 205. 

typhoid, 33—168. 

typhus, 171—299. 

yellow, 409. 
Fever, bilious remittent, 305 — 351. 

diagnosis, 375 — 377. 

duration and march, 362 — 367. 

mortality, 368. 

symptoms, 306—321. 

treatment, 382—386. 
Fever, congestive, 352 — 359. 

algid, 356. 

comatose, 354. 

delirious, 355. 

gastro-enteric, 358. 

mode of attack, 353. 

mortality, 369. 

names, 352. 

prognosis, 369. 



Fever, congestive — continued. 

type, 353. 
Fever of New England, 35, 83. 
Fever, periodical, 304 — 405. 

bibliography, 39S— 405. 

causes, 340—350. 

definition, 396. 

diagnosis, 375, 

duration and march, 362 — 367. 

introductory, 304. 

lesions, 322—339. 

mortality, 368. 

names, 305. 

prognosis, 309. 

symptoms, 306 — 321. 

theory, 378. 

treatment, 382. 

varieties, 351 — 361. 
Fever, typhoid, 

bibliography, 164 — 168. 

causes, 83 — 103. 

definition, 162. 

diagnosis, 122—133. 

duration, march, &c., 109. 

history, 36. 

lesions, 63 — 82. 

methods of description, 37. 

mortality and prognosis, 114 — 121. 

names, 34, 

relapses, 112. 

sequela;, 1 13. 

symptoms, 39 — 62. 

theory, 134—141. 

treatment, 142—161. 

varieties, 104—108. 
Fever, typhoid and remittent, 

diagnosis of, 127. 
Fever, typhoid and typhus, 

distinctions between, 123, 238, 273. 
Fever, typhus, 

bibliography, 293—299. 

causes, 203—219. 

definition, 291. 

diagnosis, 238—276. 

duration and march, 223 — 229. 

introductory, 171. 

lesions, 194—202. 

mortality, 230—237. 

names, 173. 

symptoms, 174 — 193. 

theory, 278. 

treatment, 280-292. 
Fever, yellow, 409. 

introductory, 409. 

mode of access, 411. 

names, 410. 

symptoms, 411. 
Filth, crowding, &c., 

typhoid fever, 103. 

typhus fever, 215. 

yellow fever, 467. 
Flint, Dr., 93. 
Follicular enteritis, 34, 
Fomites, 478. 
Forget, 40, 74, 167. 
Forry, Dr., 340, 
Fricke, Dr., 330. 



540 



INDEX, 



Gi"-'"iiie"- corter.:5 o". 


Identity of typhns and typhoid fever, 23S. 


ier::.i:ii:^-^:;^-32. 


Incabation, period of. 




typhoid fever in, 97. 


/..'I r. '/--^--^-' ; - - , 


typhas fever, 211. 


-'/' --.^- -''-T-'', 11-,. 


veliow fever, 493. 


Q,,.: VVl-^',/ :^ ' -;"iV.' 


Iir'ec'.ef dir.::;-.?. .4!:. 


G c c : ; md lesinns. 


Ii'ic:.: 15. 


^"■^^J:-.:iV.iv:v.^n.70. 


: 1 i 1- 143, 150, 155. 


Gil - - : 1 :- ; ' m,2»7. 


Inter--.. -.-.ei: :'i i". I:?. 


G - ^ ' ." : 1 . -' ~ • 


IntesMi;. ; = : . 


G^riiri.::..::. l':, IS!. !?:, 1S4, 137, 


- - - ■"-■•-' - . r " .= . 


- ' ^ . :^ ~ : . 


:vii:.i :r-i.-, ' . — "■. 






Lt .-.•-" t 5 t , _-■■.. - r r . - - 1 i - ; — 1 


'.■ .- — - "."'"'' • " - ~ ' ' ' : 


Gi:i-.5:. I :.. -:-. 


■;■!.. :■ -■ :rve-. -.:' . i 


G:i"i;. I :.. -: :' . 


:i:i5: 11. ;i5.:is ii: f^i'-ims, 


G-:r ^. 1 - - launal. 


:i. m; : 5 : iv t11, " ; . 


": ;i: 1 rerer in, 58. 


Ii:i5iii^ : I'f: -11 : 1 . :". 




:-:-: :.. i.ce:-.ir ::iii;,35. •: 


Hi r : Z 35,56,167,255. 


- ■ - - ; - "V, 


Hiiii;-. :ii. 469. 


: i.cal fever to, 303. 




: river, 33. 


ElrvV:-,7:''r?:^5. 


: .171. 


Heiciiie, 


1 1 ir. 409. 


biiioos fever in, 313. 


I 1 i;iia:iio«, 305,331. 


tjphoid fever, 46. 




tjphos fever, 179. 


J^, k«on. Dr. J., 36, 40, 43, 51, 59, 92, 109, 


yellow fever, 411, 421. 


143, 167. 


HeviB^, frtate of. 


Jackson, Dr. J., jr., 35. 


biiioos fever in, 315. 


Jackson, Dr. J. B. S., 129. 


typhoid fever, 50. 


Jackson, Dr. R., 296, ^1. 


typhas fever, 1S3. 


Jackson, Dr. S., 87. 


yellow fever, 427. 


Jennings, Dr., 99, 101. 


Heart, action of. 


Johnson, Dr. J., 399. 


bUioos fever in, 313. 




typhos fever, 177. 


Kimball, Dr. G., 277. 


yellow fever. 




Heart and aorta, lesions of. 


Laadoaxv, Dr., 265. 


periodical fever in, 322. 


Large intestine, lesions of. 


mtboid fever, 63. 


periodical fever in, 337. 


typhus fever, 196. 


typhoid fever. 76. 


yellow fever, 432. 


typhas fever, 199, 273. 


Heat of skin. 


yellow fever, 438. 


bUioos fever in, 311. 


Latent form. 


typhoid fever, 41. 


typhoid fever of, 105. 


typhns fever, 236. 


Latent period of contagion. 


yellow fever, 413. 


typhoid fever in, 97. 


Hemorrhage from bowels. 


typhas fever, 211. 


congestive fever in, 358- 


yellow fever, 493. 


typhoid fever, 55, 117. 


Latent period of poison. 


typhos fever- 188. 


periodical fever in, 349. 


--e^*^---- •' ' '-^ » 


Leake, Dr., 86. 


Hei:::ri-i .i'- i : :-iver,429- 


Lempriere, 488, 514, 520. 


Heii-sii, I:., li:, :v5, 191. 


Lenticalar ^>ots, 59, 241, 252, 275. 


Hiccoagh, 


Lesions in periodical fever, 322 — 339. 


typhoid fever in, 51. 


blood of, 3i»2 


ye!!c.^ 'eTe-. 4-?". 


brain, 323. 


Hildenbriii : --- C94. 


general remaite on, 338. 


HiUaiy. I r . -. . iS:. 4:3. 519. 


heart, 322. 


History of t>phoid leser, 36. 


imporunce of, 339. 


Holmes, Dr:O.W., 341. 


intestiDes, 335. 


Hosack, Dr., 453, 474, 530. 


liver, 327—332. 


Howard Dr., 329. 


Peyer's glands, 336. 


Hudson, Dr., 229, 264- 


relations, 338. 


Hangarian fever, 305. 


spleen, 332. 


Hnnter, Dr. J., 520. 


stomach, 333. 


Haxham, 190. 


Lemons in typhoid fever, S-5, 63 — S2. 



aorta, 63. 



INDEX, 



S41 



Lesions in typhoid fever — continued. 

blood, G5. 

brain, and its menibranes, 67. 

bronchia', epiglottis, &c., 66. 

children, 79. 

general remarks on, SO. 

heart, 63. 

importance, SO. 

large intestine, 76. 

liver, 79. 

lungs, i^Q. 

lymphatic glands, 77. 

pancreas, salivary glands, 

urinary and sexual organs, 79. 

perforation, 73. 

Peyer's glands, 71. 

pharynx and resophagus, QS. 

small intestines, 70. 

spleen, 7S. 

stomach, 68. 
Lesions in typhus fever, 194 — 202. 

blood of, 196. 

brain, 197. 

general remarks on, 202. 

heart, 196. 

intestines, 19S, 200. 

introductory to, 194. 

liver, 199. 

lungs, 195. 

mesenteric glands, 199, 200. 

miscellaneous, 201. 

Peyer's glands, 199,200. 

petechias, 201. 

spleen, 199, 200. 

stomach, 19S, 201. 
Lesions in yellow fever, 431 — 44S. 

blood, 432. 

brain, &c., 434. 

contents of stomach, 435. 

gall-bladder, 443. 

general remarks, 445. 

heart, 432. 

intestines, 437. 

liver, 438. 

lungs, 431. 

mesenteric glands, 445. 

spleen, 445. 

stomach, 434. 

urinary organs, 445. 
Letter from, 

Coe,Dr. 86. 

Core, Dr., 85, 127. 

Darwin, Dr., 250. 

Jennings, Dr., 99, 101. 

Kimball, Dr., 277. 

Leake, Dr., 86. 

Linton, Dr., 86. 

Mattingly, Dr., 84. 

Power, Dr., 272. 

Sutton, Dr., 85. 

Vaughan, Dr., 251. 

Wooten, Dr., 85, 127. 

Lewis, Dr. P. H., 102, 345, 415, 419, 
422, 425, 463, 4S7. 

Lind, Dr., 393, 399, 
Liver, lesions of, 

periodical fever in, 327. 



Liver, lesions of — continued. 

typhoid fever, 79. 

typhus fever, 199. 

yellow lever, 438. 
Localities of periodical fever, 340 — 343. 

Africa, 342. 

Hungarv, 342. 

Italy, 343. 

New England, 340. 

United States, 340. 

Upper Canada, 341. 
Localities of tvphoid fever, S3 — 94. 

Alabama, "85, 93. 

Birmingham, 88. 

Dedham, 92. 

Edinburgh, 88. 

France, 87. 

Georgia, 86. 

Germany, 87. 

Gibraltar, 87. 

Glasgow, 89. 

Great Britain, 88. 

Lowell, 40, 83,90, 277. 

Middle and Western States, 84. 

Minorca, 89. 

Mississippi, 86. 

Missouri, 86. 

Newcastle-upon-Tyne, 89. 

New England, 35, 90. 

New Orleans, 87. 

New York, 94. 

Pennsylvania, 87. 

Petit-Genes, 98. 

Richmond, Mass., 95, 99. 

Tennessee, 85. 

Virginia, 87. 
Localities of typhus fever, 203 — 207. 

Cities of United States, 204. 

France, 206. 

Germany, 206. 

Great Britain, 206. 

Ireland, 206. 

Middle States, 205. 

New England, 203, 205. 

New York, 205. 

Philadelphia, 172, 258. 

Rheims, 265. 

West Indies, 207. 
Localities of yellow fever, 449 — 453, 

Commercial cities, 449. 

Gulf of Mexico, 450. 

Infected districts, 452. 

Latitudes, 449. 

Ship-board, 451. 

Spain, 450. 

United States, 450. 

West Indies, 450. 
Local bleeding, 

periodical fever in, 383. 

typhoid fever, 157, 160. 

typhus fever, 283. 

yellow fever. 
Local pains, 

bilious fever in, 313. 

typhoid fever, 46. 

typhus fever, 179. 

yellow fever, 421. 



542 



INDEX. 



Lombard, Dr., 256. 

Louis, 55, 59, 154, 166, 427, 532. 

Louis and Trousseau, 413, 414, 431, 434, 

438. 
Lungs, lesions of, 

periodical fever in, 322. 

typhoid fever, 66. 

typhus fever, 195. 

yellow fever, 431. 
Luzenburg, Dr., 532.. 
Lymphatic glands, lesions of, 

periodical fever in, 335. 

typhoid fever, 77. 

typhus fever, 199. 
Lyne, Dr., 223. 

Macbride, Dr., 253. 

Macculloch, Dr., 134, 400. 

Maclean, Dr., 528. 

Maillot, 326, 354—357, 376, 390, 401. 

Malaria, 346, 456. 

Mameilonation, 69, 19S, 200, 434. 

March, 

periodical fever of, 362. 

typhoid fever, 110. 

yellow fever, 486. 
Marsh miasm, 346, 466. 
Marsh, Sir H., 212. 
Mateer, Dr., 219, 224, 231. 
Mattingly, Dr., 84, 102. 
Mental anxiety in typhus fever, 233. 
Mercurials, 

bilious fever in, 384. 

congestive fever, 387. 

typhoid fever, 143, 146, 148. 

typhus fever, 284. 

yellow fever, 506— 508, 511. 
Mesenteric glands, lesions of bilious fever 
in, 335. 

typhoid fever, 77. 

typhus fever, 199. 

yellow fever, 445. 
Meteorism, 

periodical fever in, 319. 

typhoid fever, 57, 117. 

typhus fever, 186. 

treatment of, 156. 
Mettauer, Dr., 87. 
Miasmata, 346, 466. 
Mills, Dr., 294. 
Mind, state of, 

bilious fever in, 314. 

congestive fever, 355. 

periodical fever after, 367. 

typhoid fever in, 46. 

typhus fever, ISO. 

yellow fever, 423. 
Mobile treatment of yellow fever, 512. 
Mode of access, 

bilious fever in, 306. 

congestive fever, 353. 

typhoid fever, 39, 114. 

typhus fever, 174. 

yellow fever, 411. 
Monette, Dr., 477. 
Monomania, 48. 



Morphia in congestive fever, 387, 388. 
Mortality, 

congestive fever in, 369. 

periodical fever, 368. 

typhoid fever, 114. 

typhus fever, 207, 230. 

yellow fever, 494. 
Moseiy, Dr., 367, 519. 
Mouth and tongue, 

bilious fever in, 316. 

typhoid fever, 53. 

typhus fever, 184. 

yellow fever, 417. 
M'William, Dr., 402. 
Muscles, state of, 

bilious fever in, 316. 

typhoid fever, 51. 

typhus tever, 1S3. 

yellow fever, 445. 
Muscular debility, 

bilious fever in, 316. 

typhoid fever, 51. 

typhus fever, 1S3. 

yellow fever, 426. 
Music in yellow fever, 514. 
Musk in typhoid fever, 152. 

Names, 

bilious fever of, 305. 

periodical fever, 303. 

typhoid fever, 34. 

typhus fever, 173. 

yellow fever, 410. 
Nausea and vomiting, 

bilious fever in, 318. 

congestive fever, 358. 

typhoid fever, 54. 

typhus fever, 185. 

yellow fever, 418. 
Nervous fever, 34. 
Nervous symptoms, 

bilious fever in, 313—316. 

tvphoid fever, 45 — 52. 

typhus fever, 179—184. 

yellow fever, 421 — 427. 
Neuralgia, 367. 
New England fever, 35. 
New Orleans Med. Jour., 532. 
North, Dr., 205. 
Nott, Dr., 433, 436, 441, 452. 

O'Brien, Dr., 172, 193. 
Occupation, as cause of, 

typhoid fever, 102. 

yellow fever, 460. 
Odor of body, 

typhoid fever in, 43. 

typhus fever, 176, 
(Esophagus, slate of, 

typhoid fever in, 68. 

yellow fever, 438. 
0'Halloran,Dr., 441, 529. 
Opium, 

congestive fever in, 387, 388. 

intermittent fever, 393. 

typhoid fever, 148, 153, 155. 

typhus fever, 288. 



INDEX. 



543 



Pains in the abdomen, 

bilious fever in, 319. 

typhoid fever, 56. 

typhus fever, 187. 

yellow fever, 420. 
Pains in back and limbs, 

bilious fever in, 313. 

typiioid fever, 46. 

typhus fever, 179. 

yellow fever, 4i2. 
Pancreas, lesions of, 79. 
Parallel between typhus and tvphoid fever, 

274. 
Parry, Dr. Chas., 353, 358, 3S7. 
Peiinock,Dr., 172, 194, 258. 
Percival, Dr. E., 172,218, 226, 297. 
Perforation of intestine, 

typljoid fever in, 57, 73, HI. 

treatment of, 153, 156. 
Periodical fever, 304 — 105. 
Period of access, 

periodical fever in, 309. 

yellow fever, 411. 
Periodicity, 3S0, 381. 
Peritonitis in tvphoid fever. 111. 
Perrine, Dr., 391. 
Perry, Dr., 212, 217, 261. 
Petechioe, 189, 201, 234. 
Peyer's glands, lesions of, 

bilious fever in, 335. 

constancy of, 127 — 133. 

nature, 136 — 140. 

tvphoid fever in, 71. 

typhus fever, 199, 200. 

yellow tever, 442. 
Pharynx in typhoid fever, 68. 
Physiognomy, 

bilious fever in, 315. 

congestive fever, 357. 

typhoid fever, 49, 116. 

typhus fever, 1S2. 

yellow fever, 424. 
Physical signs, 

typhoid fever in, 45. 

typhus fever, 178. 

yellow fever, 430. 
Pickels, Dr., 172, 180. 
Plugging nostrils, 152. 
Pneumonia, 

bilious fever in, 313. 

typhodes, 276. 

typhoid fever, 66, 153. 

typhus fever, 178. 
Power, Dr., 272. 
Prichard Dr., 297. 
Pringle, Sir J., 176, 190, 251, 293. 
Prognosis, 

congestive fever in, 369. 

periodical fever, 368. 

typhoid fever, 114 — 121. 

typhus fever, 234. 

yellow fever, 494 — 499. 
Prophylactics in yellow fever, 513. 
Prost, 164. 
Prostitutes, 460. 
Pulse, 

bilious fever in, 312. 



Pulse, — continued. 

typhoid fever, 43, 114. 

typhus fever, 177. 

yellow fever, 414. 
Pupil in typhus lever, 236. 
Purgatives, 

bilious fever in, 384. 

typhoid fever, 144, 158, 159. 

typhus fever, 284. 

yellow fever, 511. 
Pym, Sir Wm., 529. 

Quinine, sulphate of, 

bilious fever in, 385. 

concestive fever, 387, 389, 390, 39), 

392. 
intermittent fever, 392. 
typhoid fever, 156. 
typhus fever, 286. 
yellow fever, 

Race, influence of, 

periodical fever on, 345. 

typhoid fever, 103, 120. 

yellow fever, 458, 497. 
Recency of residence, 

typhoid fever, 102, 119. 

typhus fever, 219. 

yellow fever, 460. 
Refrigerants, 

bilious fever in, 386. 

typhoid fever, 148. 
Reid, Dr., 88, 194, 195, 196, 197, 200. 
Relapses, 

periodical fever in, 365, 394. 

typhoid fever, 112. 

typhus fever, 228. 

yellow fever, 493. 
Relations of lesions to symptoms, 

periodical fever in, 338. 

typhoid fever, 81. 

typhus fever, 202. 

yellow fever, 445. 
Remissions in periodical fever, 308. 
Remittent fever, 305—367. 
Respiration, 

congestive fever in, 359. 

typhoid fever, 44, 115. 

typhus fever, 178. 

yellow fever, 430. 
Restlessness, 

congestive fever in, 359. 

yellow {e\er, 422. 
Retention of urine, 

typhoid fever in, 118. 

typhus fever, 188. 

yellow fever, 421. 
Rhonchi, 

bilious fever in, 313. 

typhoid fever, 45. 

typhus fever, 178. 

yellow fever, 430. 
Richardson, Dr., 336. 
Rigidity of muscles, 

typhoid fever in, 51, 116. 
Rodney, yellow fever at, 532. 
Rose-colored spots, 59, 241, 252, 275. 



544 



INDEX. 



Rush, Dr., 411,415, 417, 522. 
Rutty, Dr., 20S, 233. 

Seaman, Dr., 474. 
Season, influence of, 

periodical fever on, 343. 

typhoid fever, 94, 119,277. 

typhus fever, 207. 

yellow fever, 453, 481. 
Second attacks, 

periodical fever in, 350. 

typhoid fever, 98. 

typhus fever, 216. 

yellow fever, 462. 
Senac, 364,398. 
Senses, state of, 

bilious fever in, 315. 

typhoid fever, 50. 

typhus fever, 1S3. 

yellow fever, 427. 
Sensibility of skin, 

typhoid fever in, 51. 

typhus fever, 183. 
Septenary revolution, 311. 
Sequelae, 

periodical fever of, 365, 394. 

typhoid fever, 48, 113. 

typhus fever, 228. 

yellow fever, 493. 
Sex, influence of, 

periodical fever, 345. 

typhoid fever, 101. 

typhus fever, 218, 232. 

yellow fever, 456, 497. 
Sexual appetite in yellow fever, 423, 492. 
Shapter, Dr., 405, 534. 
Shattuck, Dr., 195, 197, 259. 
Ships, 

typhus fever in, 204. 

yellow fever, 450. 
Sighing, 

congestive fever in, 359. 

yellow fever, 430. 
Signs, physical, 

typhoid fever in, 45. 

typhus fever, 178. 
Sims, Dr., 253. 
Sinapisms, 

congestive fever in, 387. 

typhus fever, 287. 

yellow fever, 530. 
Skin, state of, 

bilious fever in, 311. 

congestive fever, 356. 

typhoid fever, 41. 

typhus fever, 175. 

yellow fever, 413. 
Sleep, 

typhus fever in, 182. 

yellow fever, 424. 
Small intestines, lesions of, 

bilious fever in, 335. 

typhoid fever, 70. 

typhus fever, 198. 

yellow fever, 437. 
Smith, Dr. N., 40, 42,48, 58, 96, 146, 166. 
Smith, Dr. E. H., 473. 



Smith, Dr. S., 247. 
Softening of stomach, 

periodical fever in, 333. 

typhoid fever, 69. 

typhus fever, 198. 

yellow fever, 434. 
Somnolence, 

typhoid fever in, 49, 115. 

typhus fever, 182. 
Sordes, 54, 417. 

Spanish treatment of yellow fever, 511. 
Spleen, lesions of, 

periodical fever in, 332, 365. 

typhoid fever, 78. 

typhus fever, 199. 

yellow fever, 445. 
Sponging of body, 

typhoid fever in, 149, 150. 

typhus fever, 285. 
Sporadic cases of yellow fever, 465. 
Spotted fever, 205. 
Stages, 

periodical fever in, 308, 362. 

typhoid fever, 110. 

yellow fever, 489. 
Stewardson, Dr., 328. 
Stewart, Dr., 89, 102, 187, 190,224, 227, 

261. 
Stille, Dr., 330. 
Stimulants, 

congestive fever in, 386 — 392. 

typhoid fever, 145, 151, 155. 

typhus fever, 285. 

yellovv fever, 511, 512. 
Stomach, lesions of, 

periodical fever in, 333. 

typhoid fever, 68. 

typhus fever, 198. 

yellow fever, 434. 
Stomach, state of, 

congestive fever in, 358. 

bilious fever, 318. 

typhoid fever, 55. 

typhus fever, 185. 

yellow fever, 418. 
Stone, Dr., 461, 534. 
Strength, prostration of, 

bilious fever in, 316. 

typhoid fever, 51, 116. 

typhus fever, 183, 234. 

yellow fever, 426. 
Subsultus tendinum, 

bilious fever in, 316. 

typhoid fever, 51, 116. 

typhus fever, 184. 
Sudamina, 61. 
Suffusion of eyes, 

typhus fever in, 182. 

yellow fever, 426. 
Suffusion of face, 

typhus fever in, 182. 

yellow fever, 425. 
Sutton, Dr., 85. 
Swallowing difficult, 54. 
Sweats, 

bilious fever in, 

congestive fever, 



INDEX. 



545 



S weats — contintied. 

typhoid fever, 42. 
Swelled legs, 113. 
Saett, Dr., 324, 330. 
Symptoms of congestive fever, 3.')3 — 359. 
Symptoms of bilious fever, 306 — 321. 

abdominal, 319. 

access, 306. 

appetite, 317. 

bowels, 319. 

chills, 307. 

epigastric, 319. 

headache, 313- 

mind, 314. 

muscles, 316, 

nausea and vomiting, 31S. 

pains in back and limbs, 313. 

physiognomy, 315. 

pulse, 312. 

remissions, 308. 

senses, 315. 

skin, 311. 

thirst, 317. 

thoracic, 313. 

tongue, 316. 

type, 308. 

urine, 321. 
Symptoms of typhoid fever, 39 — 62. 

abdominal pains, 56. 

appetite and thirst, 54. 

chills, 41. 

cough, 45. 

cutaneous <?r«ptions, 59. 

delirium, 47. 

emaciation, 58. 

epistaxis, 59. 

eschars, 61. 

headache, 46. 

mode of access, 39. 

nausea and vomiting, 54. 

pains in back and limbs, 46. 

physical signs, 45. 

physiognomy. 49. 

puise, 43. 

respiration, 44. 

senses, 50. 

state of skin, 41. 

state of mind, 46. 

state ef muscles, 51. 

state of bowels, 55. 

somnolence, 49. 

tongue and mouth, 53. 

tympanites, 57. 

urine, 58. 

vigi3ance, 49. 
Symptoms of typhus fever, 174 — 193. 

appetite, 185. 

bowels, 1S6. 

blood, 192. 

chills, 175. 

cutaneous eruptions, 189. 

emaciation, 188. 

epistaxis, 188. 

eschars, 192. 

headache, 179.. 

mind, ISO- 
ad 



Symptoms of typhus fever — continued. 

mode of access, 174. 

muscles, 1S3. 

nausea and vomiting, 185. 

pain in back and limbs, 179. 

phyj5iogn()iny, 182. 

pulse, ^177. 

senses, 183. 

skin, 175. 

thoracic, 178. 

tongue and mouth, 184. 

urine, 188. 
Symptoms of yellow fever, 411 — 430. 

abdomen, 420 . 

appetite, 417. 

bowels, 420. 

chills, 413. 

color of skin, 428. 

epigastrium, 420. 

headache, 421, 

heat of skin, 413. 

hemorrhages, 429. 

local pains, 421. 

mind, 423. 

mode of access, 411. 

muscles, 426. 

nausea and vomiting, 418. 

period of access, 411. 

physiognomy, 424. 

pulse, 414, 

senses, 427. 

skin, 413. 

strength, 426. 

thirst, 417. 

thoracic, 430. 

tongue and mouth, 41*7, 

urine, 421. 

vomiting, 418. 

Taste, sense of, 

typhoid fever in, 50. 

yellow fever, 417. 
Temperature of surface, 

bilious fever in, 311. 

congestive fever, 356. 

typhoid kver, 41. 

typhus fever, 175, 236. 

yellow fever, 413. 
Theory, 

periodical fever, of, 378, 

typhoid fever, 134—141. 

typhus fever, 278. 

yellow fever, 503. 
Thirst, 

bilious fever in, 318. 

congestive fever, 358« 

typhoid fever, 54. 

yellow fever, 418. 
Thoracic symptoms, 

bilious fever in, 313. 

typhoid fever, 44. 

typhus fever, 178. 

yellow fever, 430. 
Tinnitus aurium, 

bilious fever in, 315- 

tjphoid fever, 50. 



546 



INDEX. 



Tinnitus aurium — continued. 

typhus fever, 1S3. 

yellow fever, 427. 
Tongue and mouth, 

bilious fever in, 316. 

typhoid fever, 53, 116. 

typhus fever, 184, 235. 

yeJlow fever, 417. 
Tonics, 

typhoid fever in, 148, 151, 155. 

typhus fever, 285. 

yellow fever, 51 1. 
Treatment of bilious fever, 382 — 386. 

blood-letting, 382. 

cinchona, 383. 

diaphoretics, 386. 

local bleeding, 383. 

purgatives, 383. 

refrigerants, 386. 

sulphate of quinine, 385. 
Treatment of congestive fever, 386 — 392. 

bleeding, 388. 

camphor, 387. 

capsicum, 387. 

cold dash, 388. 

heat, 387. 

opium, 387. 

stimuli, 387. 

sulphate of quinine, 387. 
Treatment of intermittent fever, 392. 
Treatment of typhoid fever, 142 — 161. 

Bouiliaud's method, 157. 

Chomel's method, 149. 

De Larroque's method, 158. 

Dr. Jackson's method, 143. 

Louis's method, 154. 

miscellaneous, 159. 

Dr. N. Smith's method, 146. 
Treatment of typhus fever, 280—290. 

affusions and ablutions, 284. 

bleeding, 280. 

camphor, 288. 

diet, 290'. 

miscellaneous, 287. 

opium, 288. 

purgatives, 284. 

stimulants and tonics, 285. 

wine, 285. 
Treatrr>ent of yellow fever, 505 — 515. 

antiphlogistic, SOS.'' 

blood-letting, 608. 

cinchona, 511. 

cold affusion, 510. 

conclusions, 514. 

mercurials, 506, 509. 

Mobile method, 512. 

preliminary, 505. 

prophylactics, 513. 

purgatives, 51 1. 

Spanish method, 511. 

stimulants, 511. 

tonics, 511. 
Trotter, Dr., 293. 
Tweedie, Dr., 249, 299. 
Twitching of tendons, 

bilious fever in, 316. 



Twitching of tendons — continued. 

typhoid fever, 51, 116. 

typhus fever, 184. 
Type of periodical fever, 308 — 311,353. 

yellow fever of, 486. 
Tympanites, 57, 319. 
Typhoid fever, 33—168. 
Typhoid entero-mesenteritis, 34. 
Typhoid state, 131. 
Typhus fever, 171—299. 

Ulceration, 

epiglottis of, 67. 

isolated follicles, 75, 76. 

Peyer's glands, 72. 

stomach, 69. 
Unity of disease, 487. 
Urinary organs, lesions of, 

periodical fever in, 338. 

typhoid fever, 79. 

typhus fever, 200. 

yellow fever, 445. 
Urine, retention of, 

typhoid fever in, 118. 

typhus fever, 188. 

yellow fever, 421. 
Urine, state of, 

bilious fever in, 321. 

typhoid fever, 58. 

typhus fever, 188. 

yellow fever, 421. 

Varieties of congestive fever, 354 — 359. 

algid, 356. 

comatose, 354. 

delirious, 355. 

gastro-enteritic, 358. 
Varieties of periodical fever, 351 — 361, 
Varieties of typhoid fever, 104 — 108. 

adynamic, 107. 

ataxic, 107. 

bilious, 107. 

inflammatory, 107. 

latent, 105. 

mucous, 107. 
Varieties of typhus fever, 220. 
Varieties of yellow fever, 

congestive, 428, 483, 484. 

inflammatory, 428, 483, 484. 

mild, 482. 

places, in different, 481. 

remittent, 487, 488. 

seasons, 481. 
Vaughan, Dr., 251. 
Vegetable decomposition, 347, 467. 
Vigilance, 

typhoid fever in, 49. 
Vision, state of, 

typhoid fever in, 50. 

typhus fever, 183. 

yellow fever, 427. 
Vomiting, 

bilious fever in, 318. 

typhoid fever, 54. 

typhus fever, 185. 

yellow fever, 418^ 



INDEX. 



547 



Vomit, black, 419. 

Walcheren fever, 305. 

Walking cases of yellow fever, 4:27, 4S3. 

Ware, Dr., 3S. 

Washington, yellow fever at, 477. 

Weather, influence of, 

periodical fever on, 343. 

typhoid fever, 119. 

typhus fever, 20S. 

yellow fever, 454. 
Wharton, Dr., 3S7. 
Willan, Dr., 253. 



\tilson. Dr. J., 425, 484, 530. 
Wine, 

typhoid fever, 145, 152. 

typhus fever, 2S5. 
Woodville, yellow fever at, 461, 46G, 533. 
Wooten, Dr., 85, 93, 127, 349. 

Yellow fever, 409—534. 
Yellowness of skin, 

bilious fever in, 312. 

typhus fever, 192, 222. 

yellow fever, 42S, 445, 447. 



THE END 



3477 



U m Ub^ 6'\2 « 



